Mentalization as Mediator between Adult Attachment and Interpersonal Distress

Breaking the cycle with trauma-focused mentalization-based treatment: theory and practice of a trauma-focused group intervention

Trauma-Focused mentalization-based treatment (MBT-TF) is an adaptation of mentalization-based treatment (MBT) specifically developed for patients suffering from attachment or complex trauma, with the possibility of co-occurring borderline personality pathology. The creation of MBT-TF was driven by previous research and observations that interventions centered on mentalizing could be significantly improved by directly addressing the impact of trauma. MBT-TF aims to mitigate symptoms that arise post-trauma, such as hyperarousal, hypervigilance, intrusions, flashbacks, avoidance behaviors, dissociative experiences, negative perceptions of self and others, and ensuing relational difficulties. Implemented as a group intervention, MBT-TF typically spans 6-12 months. From a mentalizing perspective, trauma, particularly attachment trauma, leads to a failure in processing the effects of trauma through and with others. Stress and attachment behavioral systems are disrupted, which undermines the capacity for epistemic trust, and impairs mentalizing abilities. This paper offers a concise summary of the reasoning for MBT-TF's creation, its theoretical underpinnings, and its clinical strategy for addressing the adverse impacts of trauma. It further details the treatment phases, their main goals, and their interventions, supplemented by clinical case examples that underscore MBT-TF's distinctive attributes and frequent clinical hurdles.

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.

The interplay of mentalization and epistemic trust: a protective mechanism against emotional dysregulation in adolescent internalizing symptoms

Mentalization is the ability to interpret actions as caused by intentional mental states. Moreover, mentalization facilitates the development of epistemic trust (ET), namely, the ability to evaluate social information as accurate, reliable, and relevant. Recent theoretical literature identifies mentalization as a protective factor, contrasting psychopathology and emotional dysregulation. However, few investigations have explored the concurrent associations between mentalization, ET and emotion dysregulation in the context of internalizing problems in adolescence. In the present study, 482 adolescents from the general population aged between 12 and 19 were assessed with the epistemic trust mistrust credulity questionnaire, the reflective functioning questionnaire- youth, the difficulties in emotion regulation scale, and the youth self-report. We tested the relationship between the variables through serial mediation models. Results showed that mentalization reduces internalizing problems via emotional dysregulation; ET is positively associated with mentalization but not symptomatology. Finally, both epistemic mistrust and epistemic credulity are significantly associated with internalizing symptomatology; those effects are mediated differently by difficulties in emotional regulation. In conclusion, the present study confirms mentalization's role as a protective factor in developmental psychopathology. Nevertheless, exploring the role of the different epistemic stances guarantees a better understanding of psychopathological pathways in adolescence.

Relationship Between Empathy and Interpersonal Distress of Chinese Left-Behind Children: The Role of Emotion Regulation and Gender

Introduction

Interpersonal relationship serve as crucial of social support and a sense of security for left-behind children, playing a compensatory role in mitigating the absence of familial affection. Interpersonal distress can significantly impact their mental well-being. Although previous research has established a connection between empathy and interpersonal distress, the mechanisms by which empathy triggers interpersonal distress, as well as potential gender-based variations in this relationship, remain elusive. To bridge this gap in knowledge, this study investigates the mediating influence of emotion regulation and the moderating impact of gender in the relationship between empathy and interpersonal distress.

Methods

A total of 713 rural left-behind children completed the Interpersonal Reactivity Index scale, Emotion Regulation Competence Scale, and Interpersonal Relationship Assessment Scale.

Results

Pearson correlation analyses suggested strong significant correlations among empathy, emotion regulation ability, and interpersonal distress. Path analyses indicated that emotion regulation ability mediated the relationship between empathy and interpersonal distress. Furthermore, hierarchical regression analyses suggest a moderating effect of gender in the relationship between empathy and emotion regulation ability.

Discussion

The present study reveals the role of emotion regulation ability and gender in the relationship between empathy and interpersonal distress, which has important theoretical and practical implications for the prevention and intervention of interpersonal distress in left-behind children. Moreover, it may strengthen the relationship between peer and teacher at school, and improve the quality of parent-child communication at home.

The interplay of Criterion A of the Alternative Model for Personality Disorders, mentalization and resilience during the COVID-19 pandemic

Background and aims

The COVID-19 pandemic has been accompanied by a worsening of mental health levels in some, while others manage to adapt or recover relatively quickly. Transdiagnostic factors such as personality functioning are thought to be involved in determining mental health outcomes. The present study focused on two constructs of personality functioning, Criterion A of the Alternative Model for Personality Disorders (AMPD, DSM-5) and mentalization, as predictors of depressive symptoms and life satisfaction during the COVID-19 pandemic. A second focus of the study was to examine whether this relationship was mediated by resilience.

Methods

Linear regression analyses were used to examine the relationship between personality functioning measured by Criterion A (AMPD, DSM-5) and mentalizing abilities as predictors, and depression and life satisfaction as mental health outcomes. To assess the hypothesis that this relationship is mediated by resilience a structural equation modeling approach was conducted. Data from N = 316 individuals from the general population were collected.

Results

Linear regression models revealed highly significant associations between Criterion A/mentalization and both outcome measures. Structural equation models showed a significant partial mediation by resilience of these relationships.

Conclusion

Our results support the hypothesis that mentalizing serves as a protective function by promoting resilience to the impact of stress and threats. Criterion A and mentalization performed similarly as predictors of mental health outcomes, providing empirically overlapping operationalizations of personality functioning. This finding emphasizes the importance of personality functioning in positive and negative mental health outcomes. Furthermore, our results are consistent with a mediating role of resilience.

Multiple Roles of Grit in the Relationship Between Interpersonal Stress and Psychological Security of College Freshmen

Grit, as an important positive psychological quality, has rarely been studied for its role involved in the mechanism between stress and psychological security. This article explores the moderating and mediating role of grit in the relationship between interpersonal stress and psychological security of freshmen through two studies. In study 1, freshmen from several Chinese universities (N = 1,224) were recruited to complete a battery of questionnaire, including assessments about interpersonal stress, grit, and psychological security. The moderating effect analysis showed that grit moderated the relationship between interpersonal stress and psychological security. Specifically, grit buffered the negative effects of interpersonal stress on freshmen’s psychological security, but this effect was obvious only when the level of interpersonal stress was relatively low, and decreased when the level of interpersonal stress was high. In study 2, college freshmen from another university apart from above ones (N = 604) were recruited, and we verified the results of study 1 and further explored the mediating role of grit in the relationship between interpersonal stress and security. The moderating effect analysis of study 2 also verified that of study 1. The mediating effect analysis showed that interpersonal stress not only negatively predicted psychological security, but also affected psychological security through the mediation of grit. In general, grit played a mediating and moderating role in the relationship between interpersonal stress and psychological security. This study provides first-hand evidence to explain the multiple roles of grit in the relationship between interpersonal stress and psychological security.

Psychometric evaluation of the German version of the Brief Reflective Functioning Interview

OBJECTIVES

To measure mentalization in a feasible manner, various instruments have been designed in recent years. The Brief Reflective Functioning Interview (BRFI) is a short interview that is based on the Adult Attachment Interview (AAI). The aim of both studies was to examine the psychometric properties of the German version of the BRFI and to compare them to those of the AAI.

METHODS

In Study 1, we examined 60 students using the BRFI and the AAI. In Study 2, the validity of the BRFI was examined using a mixed sample of students and patients (N = 149). Trained coders evaluated the Reflective Functioning Scale (RFS) for the BRFI and the AAI.

RESULTS

We found a significant positive correlation between the RFS total scores of the BRFI and those of the AAI. In addition, both interviews showed excellent internal consistency. We could also show that persons with mental disorders exhibit lower levels of RF score than mentally stable individuals. Women had higher RF scores in the BRFI than men in both samples. Persons whose mentalization capacity was rated below average in either the BRFI or the AAI also reported significantly lower mentalization ability in the self-assessment (p < .01).

CONCLUSIONS

Our results revealed that the RFS scores measured by the BRFI are highly comparable to those measured by the AAI. Our findings support the results of previous studies, suggesting that the BRFI is a reliable, valid and easy-to-administer alternative to the AAI.

PRACTITIONER POINTS

The German version of the Brief Reflective Functioning Interview (BRFI) proved to be a reliable and valid instrument for the assessment of reflective functioning that is shorter in terms of time to complete and the evaluation process than the measurement via the Adult Attachment Interview (AAI). Reflective functioning is negatively associated with psychopathology.

University freshmen's excessive smartphone use and psychological safety during the COVID-19 pandemic

Although excessive smartphone use has been confirmed as being associated with specific representations of mental health (e. g., anxiety, depression, wellbeing, etc.) throughout the COVID-19 pandemic, the relationship between excessive smartphone use and cognitive representations of mental health (i.e., psychological safety) is not yet fully understood. This study aimed to identify the association between excessive smartphone use and psychological safety among university freshmen during the COVID-19 pandemic; in addition, we examined the mediation effects of hardiness and interpersonal distress in this relationship. In this study, 1,224 university freshmen were selected at random from several universities in Guizhou Province of China. The Psychological Safety Scale was used to evaluate the mental health of university freshmen; the Mobile Phone Dependence Scale was used to evaluate excessive smartphone use; the Hardiness Questionnaire was used to evaluate hardiness; and the Interpersonal Relation Synthetic Diagnose Test was used to evaluate interpersonal distress. The findings showed that: (1) the greater the degree of excessive smartphone use, the more serious respondents' interpersonal distress and the lower their hardiness; (2) excessive smartphone use was not only directly related to the psychological safety of university freshmen but also indirectly related to their psychological safety through the independent mediation of hardiness and interpersonal distress, as well as through the chain mediation of hardiness and interpersonal distress. In general, excessive smartphone use in university freshmen could lead to a decline in their psychological safety. Also, hardiness and interpersonal distress play a complex role in this relationship. During the COVID-19 pandemic, interventions on the mental health of college freshmen should not only provide guidance on how to use their smartphone responsibly but also to provide them with support and guidance for the enhancement of their hardiness and improvement of their interpersonal relationships.

Mentalizing Mediates the Association between Narcissism and Psychotherapeutic Treatment Outcome in a Mixed Clinical Sample

INTRODUCTION

Pathological narcissism has been a challenge for the success of psychological treatment, whereas mentalizing has turned out to be an important mechanism of change in psychotherapy. This study focused on the classic narcissistic self (CNS) (i.e., narcissistic grandiosity) as predictor of the outcome. It further investigated whether mentalizing mediates this relation.

METHODS

A mixed clinical sample of 205 patients was investigated. The CNS scale of the Narcissism Inventory and the Mentalization Questionnaire was used to measure the features of narcissistic grandiosity and the capacity to mentalize, respectively. The symptom outcome was assessed with the Hamburg Modules for the Assessment of Psychosocial Health.

RESULTS

Contrary to our expectations, we did not find a direct association between narcissistic grandiosity and a decrease in symptoms. However, mentalizing was found to mediate the association between the CNS as well as between the narcissistic furor and outcome.

CONCLUSION

Our results confirm the ambiguity concerning the clinical significance of narcissistic grandiosity. However, in order to improve the treatment outcome in patients with narcissistic features, especially narcissistic furor, individualized treatment plans might consider introducing interventions that enhance the capacity to mentalize.

Comparing Mentalizing Abilities in Older Adults with and without Common Mental Disorders

INTRODUCTION

The concept of mentalization is of central importance not only in modern psychotherapy but also in geriatric psychotherapy. In relation to older people, deficits in some aspects of the ability to mentalize, such as the theory of mind (ToM), affect perception, and metacognitive skills, are known. However, little is known about the mentalization ability of older people with mental disorders. The aim of the present study was to investigate the mentalizing abilities of older patients with depressive and anxious symptoms.

METHODS

In this study, the ability to mentalize using the Mentalization Questionnaire (MZQ), the HEALTH-49 questionnaire, Trail-Making Test (executive functions), and Reading-the-Mind-in-the-eyes-test (ToM) was studied in a clinical (n = 150) and a nonclinical comparison sample of people (n = 150) in different age groups (40-54, 55-69, ≥70). The evaluation of the data was conducted with different statistical methods, especially variance and regression analyses.

RESULTS

The clinical sample of all age groups showed significantly poorer mentalizing skills than the nonclinical samples. There were large correlations to health-related aspects. Additionally, in the regression analysis, only the setting variable (clinical vs. nonclinical) had an influence on the MZQ score and neither gender, education, executive functions nor ToM had a significant influence. Age also had no effect and did not correlate with MZQ scores but did correlate negatively with ToM.

CONCLUSIONS

The results show the importance of mentalization concepts for mental disorders in patients in the second half of life. There are indications of an imbalance of different aspects of mentalizing ability, especially between self- and other-related mentalizing abilities. Improving this balance could be a goal of therapeutic interventions.

Psychometric Properties of the Italian Mentalization Questionnaire: Assessing Structural Invariance and Construct Validity

Mentalization is an important interpersonal ability, necessary for adaptive interpersonal relationships and emotion regulation. Deficits in mentalization have been associated with poor psychological outcomes and have been observed in patients with Borderline Personality Disorder. The Mentalization Questionnaire (MZQ) has been developed as self-report measure of mentalization deficit. The aim of the study was to investigate the dimensionality of the MZQ in a nonclinical sample composed of Italian adults from the general population and to analyze its performance in categorizing individuals with higher risk of borderline symptoms. A non-clinical sample of 1,015 adults (709 women and 306 men) was administered the Italian versions of the MZQ, the Reflective Functioning Questionnaire (RFQ), and a measure of borderline psychopathology. A revised single-factor solution fitted the data well and demonstrated metric invariance across gender. The internal consistency (Ordinal α = 0.87) and stability (r = 0.84) were satisfactory. The MZQ was moderately associated with the RFQ dimensions. The ROC curve analysis showed that the MZQ was able to discriminate satisfactorily people with higher risk for borderline symptomatology from those with lower risk. The MZQ may, therefore, be considered a reliable and valid measure of mentalization for categorizing people at higher risk for borderline pathology.

Development of a New Measure for Assessing Mentalizing: The Multidimensional Mentalizing Questionnaire (MMQ)

This research consists of two studies which aimed to: (1) evaluate the psychometric properties of a new self-report measure for the assessment of mentalizing, the Multidimensional Mentalizing Questionnaire (MMQ); and (2) investigate the ability of the instrument to discriminate between community and clinical populations. A sample of 349 participants (19% male, 81% female; M_age = 38.6, SD = 15.3) filled in the MMQ and other self-report measures, in order to assess the factor structure, reliability and some aspects of construct validity of the measure. Then, a clinical sample (N = 46; 52% male and 48% female; M_age = 33.33, SD = 12.257) and a community one (N = 50; 42% male and 58% female; M_age = 38.86, SD = 16.008) filled in the MMQ, to assess its clinical sensitivity. The factorial analysis identified six principal dimensions of the measure: reflexivity, ego-strength, relational attunement, relational discomfort, distrust, and emotional dyscontrol. The MMQ showed satisfactory psychometric properties and a theoretically relevant factor structure. Furthermore, significantly greater impairment in mentalizing was found in the clinical sample in respect of the community one. The findings are discussed in terms of clinical implications, emphasizing the usefulness of the MMQ in both research and clinical practice.

Analysis of the mediating effect of mentalization on the relationship between attachment styles and emotion dysregulation

The current study aims to explore the relationship between attachment styles, mentalization and emotion dysregulation. Moreover, the mediation effect of mentalization in the relationship between attachment and emotion dysregulation is analyzed. A sample composed of 607 participants taken from the Spanish general population completed the measures in a cross-sectional designed study. The results show that secure attachment is negatively related to emotion dysregulation dimensions, whereas insecure attachment styles show a positive correlation. Furthermore, the mentalization variables are in general significantly related to emotion dysregulation. The mediation model shows a large mediational effect size (f²  = 2.64). The results suggest that mentalization significantly mediates the relationship between emotion dysregulation and preoccupation, self-sufficiency, and childhood trauma. These results have important implications, as they indicate that clinical interventions on mentalization should reduce emotion dysregulation even in those people with a predominant insecure attachment style.

Increasing Mentalization to Reduce Maladaptive Defense in Patients With Mental Disorders

Background: There are indications of associations between the ability to mentalize and psychological defense mechanisms. However, only a few studies have focused on these associations, and even fewer have included empirical analyses. In the present study, we aimed to fill this research gap by analyzing the link between the ability to mentalize and psychological defense mechanisms in patients with mental disorders. We examined whether changes in defense mechanisms are predicted by an increase in mentalization or whether such changes are only related to reductions in psychopathology and interpersonal problems. Methods: A clinical sample of N = 89 patients was studied during and after inpatient psychiatric rehabilitation. Repeated-measures analyses of variance were performed to determine changes in mentalization, psychological defense, psychopathology, and interpersonal problems over the course of therapy and post-treatment. Linear regression analyses were used to predict the change in defense patterns based on an increase in mentalization. Results: Maladaptive defense mechanisms were significantly reduced during inpatient therapy and remained low until follow-up, whereas neurotic and adaptive defense mechanisms did not change significantly. The results of the regression analyses indicated that mentalization played an important role in the reduction in maladaptive defense during and after inpatient rehabilitation for mental disorders, whereas reductions in psychopathology and interpersonal distress were only partially associated with a reduction in maladaptive defense. Conclusion: We conclude that mentalization is vital for reducing maladaptive defense mechanisms, which are commonly associated with mental disorders. In therapy, an increase in patients' capacity to mentalize may be a practicable approach to diminish maladaptive defense mechanisms.

Self-reported reflective functioning mediates the association between attachment insecurity and well-being among psychotherapists

Objective: Subjective well-being is a crucial variable for mental health practitioners. This study examines the influence of therapists' attachment dimensions and self-reported reflective functioning on their perceived well-being. Further, it examines if reflective functioning mediates the association between attachment insecurity and well-being. Method: A total of 416 experienced psychotherapists were enrolled in this cross-sectional study, and completed self-report measures of attachment insecurity, reflective functioning, and well-being. We tested the hypothesized mediation model with path analysis that examined indirect effects. Results: Both attachment anxiety and avoidance dimensions had a significant negative association with perceived well-being with small to medium effects. "Certainty" in reflective functioning had a small positive effect on therapist well-being. Reflective functioning mediated the association between insecure attachment dimensions and well-being, suggesting that therapist's lower ability to mentalize may partially account for the effects of higher attachment insecurity on lower well-being. Conclusion: The well-being of psychotherapists with greater insecure attachment may deserve special attention, and therapists' mentalizing capacities may be targeted by researchers and trainers as a core ability to be cultivated in order to preserve therapists' professional and personal resources.

Relationship between Mentalizing and Working Conditions in Health Care

Mentalizing describes the human ability to comprehend one's own and others' mental states and is seen as one of the core competencies of psychotherapists. Current research has emphasized the importance of both early dyadic attachment as well as broader sociocultural environmental input on the development of mentalizing. This study investigates whether mentalizing skills, operationalized via reflective functioning (RF), might be influenced by training and working conditions. This study was a matched case-control comparison, cross-sectional study. RF was assessed in a total of 10 psychotherapy trainees working in private practice at the beginning (group A; n = 5) and end (group B; n = 5) of their psychotherapy training (training association: Gestalt Therapy, Institute of Integrative Gestalttherapy Vienna) and in a total of 40 health professionals (institution: General Hospital Vienna-Social Medical Center South, Vienna, Department of Psychiatry, acute psychiatric ward) at the beginning of (group C; n = 20) and without (group D; n = 20) mentalization based therapy training. The participants differed from each other regarding their training, but participants of the same institution were matched. RF scores were significantly higher in group A and B than in group C and D (A,C: p = 0.0065, Odds Ratio (OR): 0.0294; A,D: p = 0.0019, OR: 0.0132; B,C: p = 0.0065, OR: 0.0294, B,D: p = 0.0019, OR: 0.0132). RF scores were not significantly different among groups A and group B (A,B: p > 0.9999) or between groups C and D (C,D: p = 0.6050). The current study suggests that mentalizing skills might be rather slow to improve by training, but that they might be influenced by the context.

Multidirectional Pathways between Attachment, Mentalizing, and Posttraumatic Stress Symptomatology in the Context of Childhood Trauma

INTRODUCTION

Exposure to traumatic stressful events in childhood is an important risk factor for the development of posttraumatic symptomatology. From a mentalization-based developmental perspective, childhood adversity can affect attachment in children and may result in insecure attachment and impaired mentalizing abilities, which increase the lifetime risk for psychopathology. The present cross-sectional study examined the potential mediating role of attachment insecurity and impaired mentalizing on the relationship between childhood trauma and posttraumatic symptomatology.

METHOD

Adults who had experienced childhood neglect and abuse (n = 295, 184 patients with personality disorder and 111 community controls) completed self-report measures of posttraumatic stress disorder (PTSD) symptoms, dissociative experiences, adult attachment insecurity, and mentalizing.

RESULTS

Structural equation modelling results revealed that attachment insecurity together with lower mentalizing mediated the link between childhood trauma and PTSD symptoms, and lower mentalizing mediated the link between childhood trauma and dissociative experiences.

CONCLUSION

The findings show that attachment insecurity and lower mentalizing play significant mediating roles in the reporting of posttraumatic symptomatology among survivors of childhood abuse and neglect, with treatment implications for mentalization-based therapy as beneficial for individuals with a history of childhood trauma.