Epistemic Petrification and the Restoration of Epistemic Trust: A New Conceptualization of Borderline Personality Disorder and Its Psychosocial Treatment

Adverse childhood experiences and psychological maladjustment in adolescence: The protective role of epistemic trust, mentalized affectivity, and reflective functioning

INTRODUCTION

Adverse childhood experiences (ACEs) are psychosocial factors acknowledged as significant contributors to health consequences later in adolescence, including psychological maladjustment. The research suggests that, at a transdiagnostic and transtheoretical level, working on restoring epistemic trust (ET), mentalized affectivity (MA), and reflective functioning (RF) in adolescents with ACEs assumes a central role in the therapeutic process. However, there are still few studies that attempted to investigate the specific role of these sociocognitive factors in the detrimental positive association between levels of experienced ACEs during childhood and psychological maladjustment in nonclinical adolescents.

METHODS

A community sample of 306 Italian cisgender adolescents (61.4% assigned females at birth; age range 13-19 years old; Mage = 16.1, SD = 1.64) self-reported ACEs (Childhood Trauma Questionnaire-Short Form), psychological maladjustment (Strengths and Difficulties Questionnaire), ET (Epistemic Trust, Mistrust and Credulity Questionnaire), MA (Brief-Mentalized Affectivity Scale for Adolescence), and RF (Reflective Functioning Questionnaire). A multiple mediation regression analysis has been performed to explore the association between ACEs and psychological maladjustment through the interaction with socio-cognitive factors.

RESULTS

ACEs are positive predictors of psychological maladjustment later in adolescence. Regardless of gender differences, epistemic mistrust and credulity, processing and expressing emotions, and uncertainty about mental states mediated this association, while epistemic trust, identifying emotions, and certainty about mental states did not configure as significant mediators.

CONCLUSION

Findings suggest that ET disruptions and deficits in RF are risk factors, while MA is a protective factor within the link between ACEs and psychological maladjustment in adolescence. These links help to specify the role of sociocognitive factors in the development of mental problems in adolescents who have been exposed to adverse experiences in childhood.

Validation of the Argentine version of the epistemic trust, mistrust, and credulity questionnaire

Epistemic trust refers to the trust in communicated knowledge, specifically an individual's ability to regard knowledge conveyed by others as meaningful, relevant to oneself, and applicable to other contexts. This area has received considerable attention in recent psychological literature, though predominantly from a theoretical perspective. The main objective of this study was to test the factorial validity of the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ) on an Argentine setting. Based on two studies (Study 1, n = 1018; Study 2, n = 559), the factorial structure of the instrument and its internal consistency were examined (S1 Appendix). In the second study, the factorial structure was confirmed, test-retest reliability was analysed, and associations between epistemic stances and sociodemographic variables, hypomentalisation, attachment styles, childhood traumatic experiences, and anxious-depressive symptomatology were explored. A satisfactory three-factor solution with 15 items and residual correlations was found in both studies, with stable scores over time. Significant positive correlations were found with anxious and fearful-avoidant attachment, hypomentalisation, childhood traumatic experiences, and psychopathological symptomatology. Post-hoc analysis revealed that, on the one hand, gender acts as a moderator in the relationship between hypomentalisation and epistemic mistrust. On the other hand, economic level and educational level moderate the relationship between hypomentalisation and epistemic credulity. Measurement invariance across gender was tested and found satisfactory, with significant differences subsequently observed in the epistemic trust factor. In conclusion, the Argentine version of the ETMCQ provides an empirical measure for use in non-clinical samples. Its application could facilitate clinically and theoretically relevant findings.

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.

Nature heals: An informational entropy account of self-organization and change in field psychotherapy

This paper reviews biophysical models of psychotherapeutic change based on synergetics and the free energy principle. These models suggest that introducing sensory surprise into the patient-therapist system can lead to self-organization and the formation of new attractor states, disrupting entrenched patterns of thoughts, emotions, and behaviours. We propose that the therapist can facilitate this process by cultivating epistemic trust and modulating embodied attention to allow surprising affective states to enter shared awareness. Transient increases in free energy enable the update of generative models, expanding the range of experiences available within the patient-therapist phenomenal field. We hypothesize that patterns of disorganization at behavioural and physiological levels, indexed by increased entropy, complexity, and lower determinism, are key markers and predictors of psychotherapeutic gains. Future research should investigate how the therapist's openness to novelty shapes therapeutic outcomes.

Trust under development: The Italian validation of the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ) for adolescents

INTRODUCTION

In recent years, the concept of epistemic trust has emerged as a critical factor in understanding psychopathology, particularly within the context of personality disorders. A self-report instrument, the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ), has demonstrated its validity among English and Italian adult populations. However, extending its applicability to adolescents is essential for comprehending the role of epistemic trust in the development of mental disorders. The aim of this study was to validate the ETMCQ within the Italian adolescent demographic.

METHODS

Data were gathered from a wide selection of middle and high schools across Italy. The data collection started on 01/03/2022 and ended on 30/06/2022. Besides the ETMCQ (Study 1 = 662 participants, 12-18 years old, M = 15.56, SD = 2.20; 324 females, 338 males), we also administered other self-report instruments measuring mentalization, emotional dysregulation, general levels of psychopathology, and interpersonal trust in a smaller groups (Study 2 = 417 participants, aged from 12-19 years old, M = 15.64; SD = 2.08; 249 females, 168 males).

RESULTS

Our findings provide empirical validation for the theoretical framework concerning the role of epistemic trust in psychological functioning and substantiate the validity of ETMCQ as a measure to assess it among teenagers.

CONCLUSIONS

The ETMCQ is a valid and promising instrument for adolescent populations; its ease and brevity of administration could make it a valuable tool both in clinical and research contexts, shedding light on the role of epistemic trust in mental health.

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.

Trust, entrusting and the role of trustworthiness for adult survivors of child sexual abuse

BACKGROUND

Survivors of Child Sexual Abuse (CSA) are reported to have difficulties in trusting. Yet no previous study investigating CSA survivors' subjective experiences of trust exists and there is a paucity of clinical research into constructs and definitions of "trust."

AIMS

To use a phenomenological lens to investigate CSA survivors' descriptions of trust relationships and trustworthy others by privileging their subjective experience. To better understand how trust can be built within therapeutic relationships.

METHODS

A qualitative methodology using Interpretative Phenomenological Analysis was conducted within the survivor-research paradigm. The researcher was a person with lived experience of CSA who co-produced the study with CSA survivor advisors and co-constructed interviews with 17 adult CSA survivors.

RESULTS

Findings present a "Survivor Trust Enactment Model" that delineates the process of building/repairing relational trust and advancing "transactional trust." Trust is portrayed as nuanced and formed across and according to context, including the demarcation of generalised and relational trust. The findings emphasise that trustees' trustworthiness is key to building trust which challenges assumptions that survivors are deficient in trust.

CONCLUSION

The foregrounding of subjective trust experiences challenges diagnostic and clinical views on trust deficiency in adult CSA survivors. The study develops clinical constructs of trust, considers implications for clinical practice, and indicates areas for further research into trust dynamics in therapeutic relationships.

Group intervention for family members of people with borderline personality disorder based on Dialectical Behavior Therapy: Implementation of the Family Connections® program in France and Switzerland

BACKGROUND

Families and significant others of people with borderline personality disorder (BPD) show increased levels of psychological distress. Family Connections®, a 12-week group intervention based on the principles of Dialectical Behavior Therapy, was designed to provide families with both information about the disorder and emotion regulation skills. It has been progressively implemented in French-speaking European countries.

METHODS

We conducted an observational, multicenter study in France and Switzerland. In total, 149 participants of the Family Connections program were included among five centers. Burden, depression, coping, and emotion regulation were assessed before and after the intervention.

RESULTS

One-way repeated measures MANOVA showed that the burden, depressive symptoms, emotion regulation and coping all changed significantly after the intervention (p < 0.001, partial η2 = 0.297). T-tests showed that the burden significantly decreased after the intervention (p < 0.0001, d = -0.48), as did depressive symptoms (p < 0.0001, d = -0.36) and difficulties in emotion regulation (p < 0.0001, d =-0.32) whereas coping improved (p < 0.0001, d = 0.53). Two-way mixed ANOVA showed that burden reduction was stronger among female than male participants (p = 0.048, η2 = 0.027). Before the intervention, the burden was higher for female than male participants (p < 0.001). An initial linear regression showed the burden reduction to be associated with a decrease in the resignation of the participants (β = 0.19, p = 0.047). A second linear regression showed the burden reduction to be associated with the intensity of the relatives' symptoms at baseline (β = 0.22, p = 0.008) and improvement of emotional clarity of the participants (β = 0.25, p = 0.006).

CONCLUSION

This Dialectical Behavior Therapy-Based psychoeducational intervention is an appropriate way to support French-speaking European families of people with BPD.

How do we know whether treatment has failed? Paradoxical outcomes in counseling with young people

Background

In both routine practice contexts and research studies, evidence from standardized self-report symptom measures, administered pre- and post-treatment, is predominantly used to determine whether psychotherapy has been successful. Understanding the nature of unsuccessful psychotherapy requires an ability to evaluate the credibility of outcome data generated by such techniques. An important body of research has identified discrepancies between outcomes assessed through symptom measures and those obtained from other sources. However, not enough is known about the extent to which such paradoxical outcomes exist.

Objective

This study analyzes the relationship between outcomes, as assessed by a standardized self-report measure, and as assessed by ratings of young people's descriptions of change at post-counseling interviews.

Methods

Participants were 50 young people (13-16 years old) who had taken part in a trial of up to 10 weeks of school-based humanistic counseling. Our primary standardized measure was the Young Person's CORE (YP-CORE). To assess young people's experiences of counseling change, three independent raters scrutinized transcripts of post-counseling interviews, and scored levels of helpfulness on a 1 (Not at all helpful) to 10 (Extremely helpful) scale. Inter-rater reliabilities were 0.94 (Cronbach's Alpha) and 0.96 (McDonald's Omega). Sensitivity analyses were conducted to explore relationships between helpfulness ratings and other outcome measures, i.e., satisfaction with counseling (ESQ) and the Goal-Based-Outcome Tool (GBO), and process measures, i.e., the Working Alliance Inventory (WAI-S) and the Barret Lennard Relationship Inventory (BLRI).

Results

Multilevel analysis indicated that helpfulness ratings were not significantly associated with changes in YP-CORE scores. Analyzed categorically, 38% of those showing reliable improvement on the standardized measure were below the median for self-described helpfulness, and 47% of those not showing reliable change were at or above the median for self-described helpfulness. Sensitivity analyses demonstrated closer correlations between helpfulness ratings and other outcome measures (ESQ and GBO), and between helpfulness ratings and process measures (WAI-S and BLRI).

Discussion

Our results raise questions about reliance on symptom change outcome measures for defining treatment success and failure, given their disparity with clients' own descriptions of the helpfulness of therapy. Implications for practice and research are discussed.

An Evolutionary Perspective on the DSM-5 Alternative Model for Personality Disorders

Recent work has nested the Alternative Model for Personality Disorders (AMPD) within several theoretical paradigms of personality and clinical psychology (e.g., multivariate, psychodynamic). This has both spurred on additional research and aided in practical application. Connecting the model to other theoretical heuristics may lead to further advances. One candidate for such a theory is that of evolutionary psychology, which attempts to provide explanations of human behavior (including personality traits) rooted in adaptation. In this article, we review and integrate the theoretical and empirical literature on the AMPD and evolutionary psychology, providing a synthesis of the two models in the hope of furthering the research and application of both.

Utilization of Mental Health Provision, Epistemic Stance and Comorbid Psychopathology of Individuals with Complex Post-Traumatic Stress Disorders (CPTSD)-Results from a Representative German Observational Study

Background: Complex post-traumatic stress disorder (CPTSD) is a severely debilitating recently added symptom cluster in the International Classification of Diseases (ICD-11). So far, only limited information on mental health treatment-uptake and -satisfaction of individuals with CPTSD is available. The aim of this study is to investigate these aspects in a representative sample of the German general population. Methods: Participants completed the International Trauma Questionnaire (ITQ) to identify participants with CPTSD, as well as questionnaires on mental health treatment uptake and satisfaction, adverse childhood experiences, anxiety, depression, working ability, personality functioning, and epistemic trust. Results: Of the included n = 1918 participants, n = 29 (1.5%) fulfilled the criteria for CPTSD. Participants with CPTSD had received mental health treatment significantly more often than participants with PTSD or depression (65.5% vs. 58.8% vs. 31.6%; p = 0.031) but reported significantly less symptom improvement (52.9% vs. 78.0% vs. 80.0%; p = 0.008). Lower levels of epistemic trust were associated with higher CPTSD symptoms (p < 0.001). Conclusions: Our study shows that while the vast majority of individuals with CPTSD had received mental health treatment, subjective symptom improvement rates are not satisfactory. CPTSD was associated with a broad number of comorbidities and impairments in functioning. Lower levels of epistemic trust may partially explain worse treatment outcomes.

Development and validation of the Mentalizing Emotions Questionnaire: A self-report measure for mentalizing emotions of the self and other

Mentalizing describes the ability to imagine mental states underlying behavior. Furthermore, mentalizing allows one to identify, reflect on, and make sense of one's emotional state as well as to communicate one's emotions to oneself and others. In existing self-report measures, the process of mentalizing emotions in oneself and others was not captured. Therefore, the Mentalizing Emotions Questionnaire (MEQ; current version in German) was developed. In Study 1 (N = 510), we explored the factor structure of the MEQ with an Exploratory Factor Analysis. The factor analysis identified one principal (R2 = .65) and three subfactors: the overall factor was mentalizing emotions, the three subdimensions were self, communicating and other. In Study 2 (N = 509), we tested and confirmed the factor structure of the 16-items MEQ in a Confirmatory Factor Analysis (CFI = .959, RMSEA = .078, SRMR = .04) and evaluated its psychometric properties, which showed excellent internal consistency (α = .92 - .95) and good validity. The MEQ is a valid and reliable instrument which assesses the ability to mentalize emotions provides incremental validity to related constructs such as empathy that goes beyond other mentalization questionnaires.

Improvements of complex post-traumatic stress disorder symptoms during a multimodal psychodynamic inpatient rehabilitation treatment - results of an observational single-centre pilot study

Background: Complex post-traumatic stress disorder (CPTSD) describes chronic disturbances in self-organization (i.e. affect dysregulation; negative self-concept; severe difficulties in relationships) which are frequently observed in survivors of prolonged, repeated or multiple traumatic stressors. So far, evidence of psychodynamic treatment approaches for CPTSD is scarce.Methods: In this single-centre observational pilot study, symptom change during a 6-week psychodynamic inpatient treatment in a multimodal psychosomatic rehabilitation centre was evaluated using repeated measures analyses of variance (ANOVAs). Patients completed questionnaires on PTSD and CPTSD symptoms (ITQ), anxiety, depression and somatization (BSI-18), functional impairment (WHODAS) and epistemic trust, mistrust and credulity (ETMCQ) before (T1) and at the end of treatment (T2). A hierarchical linear regression analysis was calculated to identify factors associated with improved CPTSD symptoms.Results: A total of n = 50 patients with CPTSD were included in the study, of whom n = 40 (80%) completed treatment. Patients reported a significant reduction of CPTSD symptoms during treatment with a large effect size (-3.9 points; p < .001; η2 = .36), as well as a significant reduction of psychological distress (p < .001; η2 = .55) and functional impairment (p < .001; η2 = .59). At the end of treatment, 41.0% of patients no longer fulfilled the diagnostic criteria for CPTSD. Changes in epistemic stance included improved epistemic trust (β = -.34, p = .026) and decreased epistemic credulity (β = .37, p = .017), which together with lower age (β = .43, p = .012) and lower depression levels at baseline (β = .35, p = .054) were significantly associated with baseline adjusted mean change of CPTSD symptoms during therapy and explained 48% of its variance.Discussion: In our study, patients reported a significant reduction of CPTSD symptoms and comorbid symptoms during a multimodal psychodynamic inpatient rehabilitation treatment. Improved epistemic trust may facilitate the establishment of a trusting therapeutic relationship, thus fostering an environment of openness for knowledge transfer (i.e. social learning) and the exploration of diverse viewpoints and perspectives in the therapeutic process.

Clinical Evidence, Triangulation of Perspectives and Contextualization. Part 1: The Beginning of Carla's Treatment

We propose to critically evaluate and strengthen the level of clinical evidence in psychoanalysis, using a strategy of triangulating clinical phenomena from different perspectives and increasing contextual knowledge. Insufficient discussion of alternative hypotheses and limited contextual information are two Achilles heels of psychoanalytic case presentations. We examine the concept and quality standards of clinical evidence in psychoanalysis and related disciplines, with particular attention to the contribution of the three-level model (3-LM). We analyze the case of a patient treated with transference-focused psychotherapy (TFP), making explicit the theoretical-clinical agreements and disagreements of the authors. We discuss the strengths and limitations of triangulation and contextualization, concluding that they make clinical work and psychoanalytic writing more reliable, transparent, auditable, and replicable.

How negative self-views may interfere with building positive relationships: An experimental analogue of identity dysfunction in borderline personality disorder

INTRODUCTION

A disturbed, negative sense of self is associated with various interpersonal difficulties and is characteristic of disorders such as borderline personality disorder (BPD). Negative self-views may affect an individuals' ability to build positive relationships, including a therapeutic relationship. However, it is not yet well understood how identity disturbances give rise to interpersonal difficulties. Using an experimental analogue design, we tested whether identity disturbances are associated with interpersonal difficulties.

METHODS

Participants were university students (N = 43, age M = 20.51 (SD = 3.08), women N = 32 (74.4%)) who reported moderate to high levels of BPD features, with 34.9% reporting significant BPD features as measured by the Borderline scale of the Personality Assessment Inventory (PAI-BOR). In a within-subject experimental paradigm using a Social Feedback Task, participants received negative, intermediate, and positive evaluations, supposedly from a panel. Using multilevel models, we tested whether negative self-views were associated with how much the participants liked, trusted, and felt close to each of the three panel members who provided either predominantly negative, intermediate, or positive feedback.

RESULTS

People with more negative self-views reported lower mood in response to positive feedback. In addition, where people with more positive self-views felt better when receiving feedback that was congruent with their self-views, people with more negative self-views did not report a better mood. Importantly, people with negative self-views felt lower desire to affiliate with the member who provided predominantly positive feedback. Affiliation was not affected when feedback was given by the negative member and intermediate member to those with negative self-views.

CONCLUSIONS

The findings validated that those with more negative self-views anticipated and expected more negative responses from others. Negative self-views, as relevant for BPD, may explain how people relate differently to those giving different types of feedback. Pervasive negative self-views may interfere with building new relationships including the therapeutic alliance. It may be helpful for clinicians to be aware of the potential challenges around creating a supportive therapeutic relationship for patients with negative self-views. Overly positive affirmations made by clinicians may inadvertently lower the patient's mood and may impede alliance formation.

"You can't really have a relationship with them because they just ask you questions": understanding adolescent dropout - an empirical single case study

Introduction

High dropout rates are common in youth psychotherapy, including psychoanalytic psychotherapy, yet the reasons behind this trend remain obscure. A critical focus to enhance adolescent engagement could be the therapeutic alliance, particularly in resolving alliance ruptures. This study sought to clarify the complex relationships between the therapeutic alliance, encompassing alliance ruptures and resolutions, and dropout within the context of poor outcome. It investigated a single case of an adolescent with depression who dropped-out of Short-Term Psychoanalytic Psychotherapy, without showing clinical improvement.

Method

Data was garnered from diverse sources, including questionnaires, interviews, and session recordings, and analyzed through a mixed-method longitudinal framework. This encompassed views from the adolescent, therapist, parents, and external evaluators.

Results

The study identifies several factors impacting the decision to drop out, including initial profound distrust toward the therapist, a complex and difficult therapeutic relationship characterized by unresolved alliance ruptures, and sporadic attendance. External factors including minimal parental engagement with therapy were also seen as detrimental to the adolescent's involvement and progress.

Discussion

The research underscores the challenges in engaging adolescents, especially when there may be distrust of professionals, and in the absence of parental involvement with treatment.

Iranian adaptation of the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ): Validity, reliability, discriminant ability, and sex invariance

INTRODUCTION

Epistemic trust, or trust in transmitted knowledge, has been proposed as a critical factor in psychopathology and psychotherapy. This study aimed at evaluating the psychometric properties of the Epistemic Trust, Mistrust, and Credulity Questionnaire (ETMCQ) in Iran.

METHOD

Data were collected from 906 participants. Along with the ETMCQ, measures of mentalizing, mindfulness, perspective-taking, attachment, emotion dysregulation, and borderline personality disorder were administered. Confirmatory factor analysis and exploratory structural equation modeling (ESEM) were used to determine factorial structure.

RESULTS

The ESEM model showed an acceptable fit and outperformed the confirmatory model. A 14-item version of the ETMCQ was retained after examining item performance. Our findings also established criterion-related validity for mistrust and credulity, an acceptable internal consistency for credulity, discriminant power for mistrust and credulity in detecting positive screens for borderline personality disorder, and measurement invariance across sexes.

CONCLUSION

This study provides evidence for the cross-cultural applicability of the ETMCQ. Nonetheless, the validity of the trust and internal consistency of the mistrust subscale require particular attention in future research.

Borderline personality disorder features are associated with inflexible social interpretations

BACKGROUND

Borderline personality disorder (BPD) is thought to involve aberrant social learning, including impaired revision of social interpretations with new evidence (social interpretation inflexibility). However, this topic has received little empirical attention outside of specific literatures, such as moral inference or behavioral economics. Further, the contribution of comorbid depression to BPD-related interpretation inflexibility has not yet been assessed.

METHODS

In two independent samples (Study 1: N = 213; Study 2: N = 210, oversampled for BPD features), we assessed the associations between BPD symptoms, depressive symptoms, and task-based measures of social interpretation flexibility.

RESULTS

We found that BPD symptoms, particularly volatility of identity and relationships, were associated with less revision of social interpretations with both positive and negative evidence. Meanwhile, depressive symptoms were associated with a pattern of less revision of social interpretations with positive versus negative information.

LIMITATIONS

The use of cross-sectional, crowdsourced samples limits causal interpretations. Translation to clinical populations should be assessed in future studies.

CONCLUSIONS

Results suggest that inflexible social interpretations across valences may be a feature of BPD-related pathology, and could be connected to symptoms involving volatility in social contexts. Future studies should investigate whether treatments geared toward increasing the flexibility of social interpretations are effective in treating BPD symptoms, especially those involving interpersonal difficulties.

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.

Commentary: Special Issue on Interpersonal Trust

This commentary reviews the Journal of Personality Disorders special issue "Interpersonal Trust and Borderline Personality Disorder: Insights From Clinical Practice and Research," published in Volume 37, Number 5, October 2023.

The Innate Capacity for Representing Subjective Experience: The Infant's Mind is Neither Primitive nor Prerepresentational

The author cites the prominence of theories that locate serious adult psychopathology in the preverbal infant's inability to formulate or represent traumatic experience. The work of two such authors, H. Levine and D. B. Stern, is briefly considered. The frame of reference for this investigation is that clinical and academic research findings are highly relevant to psychoanalytic theorizing. It is argued that when such findings are considered, a view of the infant with "primordial and unrepresented" states of mind has little evidence to support it. In fact, research findings summarized herein point to an opposite view: that of the "competent infant," one with highly accurate perceptual discrimination capacities and an innate ability to register and represent subjective experience in both procedural and declarative memory, even prenatally. Given the infant's competencies, it seems implausible to hold that representational deficits are at the heart of serious adult psychopathology, which is instead seen to be the result of defensive maneuvers against unknowable and unspeakable truth rather than the absence of a preverbal representational capacity. Current research findings seem to pose a significant challenge for psychoanalytic theories that espouse "primitive mental states"; "unrepresented," "unformulated," or "unsymbolized" experience; or "nonconscious" states.

The development of the Epistemic Trust Rating System (ETRS)

OBJECTIVE

The present study introduces and validates the Epistemic Trust Rating System (ETRS), an observer-based measure designed to assess epistemic trust (ET) within psychotherapy. ET in psychotherapy has gained much theoretical attention as a critical component in the therapeutic context, given its inherent link to social communication. However, its empirical validation remains pending, largely due to the absence of a refined instrument to gauge ET levels within the therapy environment. Therefore, this study aimed to translate ET's theoretical construct into tangible markers within the therapeutic context.

METHOD

One hundred eighteen patients enrolled in a randomized controlled trial received psychodynamic psychotherapy for depression. Incorporating top-down theoretical considerations with bottom-up empirical observations yielded an overall ETRS score accompanied by three distinct sub-scales, each assessing a singular ET element: one gauges the patient's propensity to share; another measures the degree to which "we-mode" moments are achieved within the session; and the third evaluates the patient's receptiveness to learning.

RESULTS

The findings demonstrate the psychometric robustness of the ETRS, with good internal consistency, interrater reliability (ICC(1,8) = .86-.90), and convergent (r = .23-.29) and discriminant validity (r = -.10).

CONCLUSION

The current study highlights the ETRS as a promising tool bridging theory and empirical exploration, enhancing our understanding of epistemic trust in psychotherapy.

Epistemic trust: a comprehensive review of empirical insights and implications for developmental psychopathology

Originally rooted in philosophy and sociology, the concept of epistemic trust has recently transitioned to developmental psychopathology, illuminating social-cognitive processes in psychopathology. This narrative review synthesizes empirical evidence on epistemic trust to inform future research. A literature search highlighted 3 areas: i) the development of selective trust in children; ii) epistemic trust in non-clinical adults; iii) its link to mental health. Young children demonstrate selective learning from reliable sources using epistemic cues. Empirical studies beyond childhood were greatly facilitated in the last 2 years with the introduction of the Epistemic Trust, Mistrust and Credulity Questionnaire, a self-report scale measuring epistemic stance. Cross-sectional studies pinpointed dysfunctional epistemic strategies as factors in mental health vulnerability, and some qualitative work offered initial evidence linking restored epistemic trust to effective psychotherapy. For future research, we propose focusing on 3 primary areas. First, empirical investigations in adolescent samples are needed, as adolescence seems to be a pivotal phase in the development of epistemic trust. Second, more experimental research is required to assess dysfunctional and functional epistemic stances and how they relate to vulnerability to mental health disorders. Finally, intervention studies should explore the dynamics of epistemic stances within and between therapy sessions and their impact on therapeutic outcomes.

Childhood maltreatment, dissociation and borderline personality disorder: Preliminary data on the mediational role of mentalizing in complex post-traumatic stress disorder

OBJECTIVES

Treatments for borderline personality disorder (BPD) and post-traumatic stress disorder (PTSD) are less effective for patients with co-occurring symptoms of both disorders, who are considered to have complex PTSD (cPTSD), compared with patients with either condition alone. Evidence suggests that co-occurrence of symptoms indicates greater impairment in mentalizing. This study examines evidence for targeting mentalizing when treating individuals with co-occurring symptoms, irrespective of their exposure to developmental trauma and, for the first time, investigates the mediational role of mentalizing in the associations between BPD symptomatology and cPTSD.

DESIGN

We identified in a routine clinical service a group of patients with BPD, with or without co-occurring symptoms of PTSD. We hypothesized that patients with co-occurring symptoms and a history of childhood maltreatment will show more severe clinical profiles and greater mentalizing problems, which in turn lead to symptoms consistent with cPTSD.

METHOD

Clinical profiles of 72 patients with BPD (43 with and 29 without co-occurring symptoms of PTSD; mean age in both groups 28 years, 79% and 83% female, respectively) were identified using the Structured Clinical Interview for DSM-IV Axis II Disorders. Patients completed self-report measures of BPD and PTSD symptoms, well-being, dissociation and reflective functioning. Childhood trauma histories were evaluated.

RESULTS

Compared with patients with BPD-only, those with co-occurring BPD and PTSD showed greater severity in terms of BPD and dissociative symptoms, met a broader range of BPD diagnostic criteria, had a greater sense of personal worthlessness and self-evaluated their well-being as considerably diminished. This group was also more inclined to recall increased instances of childhood sexual abuse. In a mediation analysis, mentalizing acted as a partial mediator for the relationship between BPD severity and cPTSD, as well as between dissociative symptoms and cPTSD. Interestingly, mentalizing did not mediate the relationship between childhood sexual abuse and cPTSD.

CONCLUSIONS

Overall, the correlational findings are consistent with an intended focus on mentalizing to treat cPTSD symptoms in individuals who also meet criteria for a diagnosis of BPD.

Beyond Mentalizing: Epistemic Trust and the Transmission of Culture

We explore the interpersonal origins of human culture, arguing that culture emerges as a necessary consequence of our helplessness in infancy, which in turn requires a greater degree of collaboration and social organization than is necessary for other mammals. We propose a model of cultural transmission that depends on a dyadic interpersonal process whose vicissitudes can have a lifelong impact. We explore the role played by imagining subjectively experienced psychological states and processes in others, which we have defined as mentalizing, in the process of cultural transmission, and propose that mentalizing is key to the establishment of epistemic trust-that is to say, an experience of trust that enables the individual to absorb and use the knowledge they are being offered. We suggest that psychoanalysis can be viewed as a paradigmatic example of a process of transferring knowledge from one human being (the teacher, the caregiver, the analyst) to another (the learner, the young person, the patient) and argue that the mechanisms of psychic change in analysis cannot be fully understood without appreciating this aspect of the biological/evolutionary origins of our essential humanity. Finally, we discuss the clinical implications of the model we are proposing for the psychoanalytic process.

Associations of mentalization and epistemic trust with internalizing and externalizing problems in adolescence: A gender-sensitive structural equation modeling approach

INTRODUCTION

Mentalization, operationalized as reflective functioning (RF), allows individuals to interpret actions as caused by intentional mental states. Previous research highlighted the gender-specific associations between adolescents' internalizing and externalizing difficulties and mentalizing impairments. In addition, research suggested that mentalizing facilitates the creation of epistemic trust (ET) to evaluate social information as accurate, reliable, and relevant. However, few investigations explored the concurrent associations between RF, ET, and adolescent psychopathology.

METHODS

A sample of 447 Italian cisgender adolescents (57% assigned females at birth; age range 12-19 years old; Mage  = 15.54, SD = 1.98) self-reported RF (RFQY-5), ET towards mother, father, and peers (IPPA) and mental health problems (YSR-112). Gender-specific structural equation modeling explored the associations between RF, ET, and internalizing/externalizing problems.

RESULTS

Results suggested an excellent fit for the theoretical model and revealed gender-related associations. In females, findings suggest that ET mediates the association between RF and psychopathology, with indirect associations from RF through ET to lower internalizing and externalizing problems. However, in males, RF and ET display independent associations with psychopathology.

CONCLUSION

Overall, findings suggest that ET might be a transdiagnostic factor playing different roles associated with adolescent psychopathology. Indeed, links between RF and ET might help to explore gender differences in mental health problems in this developmental phase.

Impact of the Mediational Intervention for Sensitizing Caregivers on Mentalizing in Orphans and Vulnerable Children in South Africa

The Mediational Intervention for Sensitizing Caregivers (MISC) is a mentalization-based intervention which aims to enhance caregiver sensitivity and responsiveness. MISC has demonstrated treatment effects on mental health problems of Orphans and Vulnerable Children (OVC) in South Africa working with Community-Based Organization (CBO) careworkers as the point of intervention. Recent elaboration of mentalization-based theory points to alternate figures in a child's early environment as critical resources for enhancing children's mentalizing capacity. In this study we evaluated the treatment effect of MISC on children's mentalizing capacity at baseline and following 12-months of the intervention, controlling for the effects of age, gender, orphan status, socioeconomic status, quality of the home environment, and mental health difficulties at baseline. MISC and Treatment as Usual (TAU) groups were compared using a mixed model linear regression. Results demonstrated significant effects of MISC, time, and mental health difficulties on mentalizing capacity. To our knowledge, this study is the first mentalization-based caregiver intervention to demonstrate treatment effects on child mentalizing capacity, and MISC is the first mentalization-based caregiver intervention to focus on paraprofessionals as the point of intervention.

The development and psychometric evaluation of the Questionnaire Epistemic Trust (QET): A self-report assessment of epistemic trust

Epistemic trust (ET) refers to the predisposition to trust information as authentic, trustworthy and relevant to the self. Epistemic distrust - resulting from early adversity - may interfere with openness to social learning within the therapeutic encounter, reducing the ability to benefit from treatment. The self-report Questionnaire Epistemic Trust (QET) is a newly developed instrument that aims to assess ET. This study presents the first results on the psychometric properties of the QET in both a community and a clinical sample. Our findings indicate that the QET is composed of four meaningful subscales with good to excellent internal consistency. The QET shows relevant associations with related constructs like personality functioning, symptom distress and quality of life. QET scores clearly distinguish between a clinical and community sample and are associated with the quality of the therapeutic alliance. The QET provides a promising, brief and user-friendly instrument that could be used for a range of clinical and research purposes. Future studies with larger samples are needed to strengthen construct validity and to investigate the value of the QET to predict differential treatment responses or to study mechanisms of change.

The cultural change narrative as a core component of therapeutic change

Introduction

Research indicates a similar effect of Mentalization-based treatment (MBT) and Dialectical behavior therapy (DBT) for borderline personality disorder (BPD). However, there is a paucity in studies investigating the change narrative received from and developed in these treatments. The aim of the present study is to investigate similarities and differences in the change narratives provided by MBT and DBT, and how these narratives reflect the rationale, explanations, and procedures of the provided treatment.

Methods

The study is a qualitative analysis of seven interviews conducted by the authors. Three of the participants had received MBT, and four of the participants had received DBT. This study presents an Interpretative Phenomenological Analysis (IPA) of the change narratives received in two specialized treatments for BPD.

Results

The main findings from the IPA were that the change narratives described by the participants reflected the treatment they received. The DBT participants highlighted explicit learning of tools and techniques, with predictable and safe therapists. In contrast, the MBT participants emphasized a long-lasting process of exploring to create procedural learning with therapists who followed their lead.

Discussion

The participants' stories of change shed light on how a change narrative was developed, and therefore how the rationale, explanations and procedures were conveyed differently by MBT and DBT.

Trust in Therapeutic Work With Adolescents With and Without Personality Disorders: A Transference-Focused Therapy Perspective

Trust is central to successful therapeutic work with adolescents, but establishing trust can be challenging, especially with adolescents with personality disorders. We present our understanding of trust in working with adolescents with and without personality disorders. We draw on complementary and overlapping perspectives, namely the attachment model, Kernberg's object relations model, and Fonagy's mentalization model. In Kernberg's object relations conceptualization, difficulties in trust experienced by patients with borderline personality disorders result from paranoia associated with splitting and identity diffusion. In Fonagy's mentalization model, epistemic trust is rooted in early experiences of being responded to and understood. We outline how techniques used in transference-focused psychotherapy for adolescents promote the development of the adolescent's capacity to trust by facilitating identity integration, thus reducing paranoia. Finally, we use two clinical case illustrations to demonstrate how trust unfolds in working with adolescents with and without personality disorders.

Transference-Focused Psychotherapy and Trust Processing in BPD: Exploring Possible Mechanisms of Change

Individuals with borderline personality disorder (BPD) struggle to identify whom they can safely trust, and this struggle contributes to profound emotional turmoil in their close relationships. Transference-focused psychotherapy (TFP) is an application of object relations theory (ORT) that posits that polarized mental representations of self and other define the personality organization of BPD. TFP aims to utilize a clear treatment frame coupled with an analysis of the therapeutic relationship (i.e., the transference) to help individuals with BPD integrate their polarized mental representations. Improvement in the capacity to trust others is inherent in the mechanisms of change in TFP. In this article, a social cognitive model of trust processing provides a new lens through which we formulate how TFP may enhance trust processing in BPD. Recent evidence from randomized clinical trials supports the argument that TFP may intervene with BPD in a way that is concordant with uniquely improved trust processing.

Accuracy and Bias in Facial Trustworthiness Appraisals in Borderline Personality Disorder

Individuals with borderline personality disorder (BPD) have shown a negativity bias, whereas the general population has shown a positivity bias in their trustworthiness appraisal of others. We tested if individuals with BPD are more negative but also more realistic with their appraisals. Trustworthiness was objectified on an external criterion. The influence of childhood trauma was investigated. Facial photographs of peace prize laureates and sentenced murderers were presented. Participants with BPD and healthy controls (HC) rated the trustworthiness of the targets. Bias and sensitivity were measured using signal detection theory. The BPD group was more negatively biased compared to HC, but not more sensitive in discriminating between the two groups. When correcting for experienced childhood abuse and neglect, the authors found that group differences in bias disappeared. Individuals with BPD might not be more sensitive in discriminating between, on average, more or less trustworthy targets, but they have developed a negativity bias to ensure the detection of untrustworthiness.

Corrective Experiences to Enhance Trust: Clinical Wisdom From Good (Enough) Psychiatric Management

Unstable trust within social interchange underlies the symptom constellation of borderline personality disorder (BPD), resulting in preoccupation with intense dyadic relationships, limited capacity for social collaboration, and constricted social networks. Good Psychiatric Management (GPM) provides a distilled formulation of how interpersonal hypersensitivities drive the engine of BPD's symptomatic oscillations in both affect and attachment. The authors summarize clinically relevant conclusions from the empirical literature on trust in BPD, synthesize it with selected ideas from other empirically supported interventions, and distill a formulation of how the GPM approach can address problems of trust in BPD with strategies most clinicians can use to improve their work with patients. GPM's clinical management approach utilizes common factors in psychotherapy to structure collaboration with patients to be accountable partners in treatment, rely on themselves more to diminish unrealistic demands on others, and function more effectively in arenas that expand and stabilize their social network.

Mediation effect of anxious attachment on relationship between childhood trauma and suicidal ideation sensitive to psychological pain levels

BACKGROUND

Childhood trauma (CT), depression, and psychological pain are known predictors of suicidal ideation. Recent literature additionally highlights the importance of the attachment system.

METHODS

We aimed to predict suicidal ideation through CT, attachment, and psychological and social pain by using mediation models aiming to predict suicidal ideation through CT (predictor) and attachment (mediator). In the same models, we introduced psychological or social pain as a moderator of the relationship between attachment, CT, and suicidal ideation. We included 161 depressed patients and assessed depression, attachment, CT, suicidal ideation, psychological pain, and social pain.

RESULTS

We found (1) a complete mediating effect of anxious attachment (a2b2 = 0.0035, CI95% = [0.0010; 0.0069]) on the relationship between CT on suicidal ideation, and (2) a significant complete conditional mediating effect of anxious attachment and psychological pain (index of moderated mediation VAS: 0.0014; CI95% = [0.0002; 0.0032]) but not social pain on the relationship between CT and suicidal ideation. Both models were controlled for history of suicidal attempt, depression severity, and sex.

CONCLUSIONS

Our results suggest a developmental profile of suicidal ideation in mood disorder that is characterized by the presence of CT and insecure attachment, especially anxious attachment, that is sensitive to experiences of psychological pain. Nevertheless, we cannot conclude that avoidantly attached individuals do not present the same mechanism, as they may not disclose those ideas.

The contribution of adverse childhood experiences to postpartum maternal reflective functioning: A prospective examination of the role of maternal disintegrative responses and personal growth

BACKGROUND

Adverse childhood experiences (ACE) may negatively impact a mother's parental reflective functioning. However, if coping with this difficulty generates personal growth, it may help her to function in a positive reflective manner with her child.

OBJECTIVE

In a two-phase prospective study, we examined a mediation model and a moderated mediation model depicting the contribution of ACE (Phase 1), maternal disintegrative responses (intrusive thoughts and dissociative experiences; Phase 1), and personal growth (Phase 2) to maternal reflective functioning (Phase 2) as expressed in three dimensions: Pre-mentalizing Modes (PM), Certainty about Mental States (CMS), and Interest and Curiosity (IC).

METHOD

Three hundred and eighty-five Israeli women participated in the study 16 weeks after childbirth (Phase 1) and again 6-10 months postpartum (Phase 2).

FINDINGS

The mediation model revealed that maternal dissociative experiences fully mediated the relationship between ACE and PM, and maternal intrusive thoughts fully mediated the relationship between ACE and CMS. However, the moderated mediation model showed that these mediation relationships were dependent on the level of personal growth reported by the mother.

CONCLUSIONS

The findings highlight the vulnerability of mothers with ACE to function in a less reflective manner, as well as the effect of personal growth on their maternal functioning.

Attachment as a predictor of dropout in mentalization-based treatment

OBJECTIVES

Although treatments of patients with borderline personality disorder (BPD) were historically associated with relatively high dropout rates, dropout rates in contemporary evidence-based treatments for BPD are typically substantially lower. However, only a few studies have investigated dropout rates in mentalization-based treatment (MBT), and even fewer have investigated predictors of dropout in this type of treatment. In this study, we investigated dropout rates in two types of MBT (day hospital MBT [MBT-DH] and intensive outpatient MBT [MBT-IOP]) using data from a recent multicenter randomized clinical trial. Given the central importance of attachment considerations in MBT, we also investigated the relationship between dropout in these two treatments and attachment dimensions.

DESIGN

Within a multicenter randomized clinical trial, 114 BPD patients were randomized to MBT-DH (n = 70) or MBT-IOP (n = 44).

METHODS

Dropout in both types of MBT was investigated using descriptive analyses, and its association with attachment anxiety and attachment avoidance, as measured by the Experiences in Close Relationships questionnaire at baseline, was investigated using regression analyses.

RESULTS

Dropout rates were relatively low (10.5% across both types of MBT) and did not significantly differ between groups (11.4% in MBT-DH, 9.1% in MBT-IOP). Attachment avoidance and attachment anxiety did not impact dropout, nor did their interaction or the interaction with the type of MBT.

CONCLUSIONS

Low dropout rates in both types of MBT indicate a high level of engagement of patients in both programmes. Attachment dimensions were not associated with dropout, consistent with the principle that MBT is tailored to each individual's needs. More research is needed, however, to investigate to what extent attachment is a dynamic context-bound adaptive process rather than a static personality feature.

Mentalizing and epistemic trust as critical success factors in psychosomatic rehabilitation: results of a single center longitudinal observational study

Background

Inpatient psychosomatic rehabilitation is a key treatment for patients with mental health issues. However, knowledge about critical success factors for beneficial treatment outcomes is scarce. The aim of this study was to evaluate the association of mentalizing and epistemic trust with the improvement of psychological distress during rehabilitation.

Methods

In this naturalistic longitudinal observational study, patients completed routine assessments of psychological distress (BSI), health-related quality of life (HRQOL; WHODAS), mentalizing (MZQ), and epistemic trust (ETMCQ) before (T1) and after (T2) psychosomatic rehabilitation. Repeated measures ANOVA (rANOVAs) and structural equation models (SEMs) were calculated to investigate the association of mentalizing and epistemic trust with the improvement in psychological distress.

Results

A total sample of n = 249 patients were included in the study. Improvement in mentalizing was correlated with improvement in depression (r = 0.36), anxiety (r = 0.46), and somatization (r = 0.23), as well as improved cognition (r = 0.36), social functioning (r = 0.33), and social participation (r = 0.48; all p < 0.001). Mentalizing partially mediated changes in psychological distress between T1 and T2: the direct association decreased from β = 0.69 to β = 0.57 and the explained variance increased from 47 to 61%. Decreases in epistemic mistrust (β = 0.42, 0.18-0.28; p < 0.001) and epistemic credulity (β = 0.19, 0.29-0.38; p < 0.001) and increases in epistemic trust (β = 0.42, 0.18-0.28; p < 0.001) significantly predicted improved mentalizing. A good model fit was found (χ2 = 3.248, p = 0.66; CFI = 0.99; TLI = 0.99; RMSEA = 0.000).

Conclusion

Mentalizing was identified as a critical success factor in psychosomatic inpatient rehabilitation. A key component to increase mentalizing in this treatment context is the improvement of epistemic mistrust.

Alternation in functional connectivity within default mode network after psychodynamic psychotherapy in borderline personality disorder

BACKGROUND

Borderline personality disorder (BPD) is characterized by impairments in emotion regulation, impulse control, and interpersonal and social functioning along with a deficit in emotional awareness and empathy. In this study, we investigated whether functional connectivity (FC) within the default mode network (DMN) is affected by 1-year psychodynamic psychotherapy in patients with BPD.

METHODS

Nine BPD patients filled out the demography, Interpersonal Reactive Index (IRI), Toronto Alexithymia Scale 20 (TAS 20), the Alcohol, Smoking, and Substance Involvement Screening Test (ASSIST), and the Borderline Evaluation Severity over Time (BEST) questionnaire. The BPD group (9F) and the control group (9F) had a mean ± SD age of 28.2 ± 5.3 years and 30.4 ± 6.1 years, respectively. BPD subjects underwent longitudinal resting-state fMRI before psychodynamic psychotherapy and then every 4 months for a year after initiating psychotherapy. FC in DMN was characterized by calculating the nodal degree, a measure of centrality in the graph theory.

RESULTS

The results indicated that patients with BPD present with aberrant DMN connectivity compared to healthy controls. Over a year of psychotherapy, the patients with BPD showed both FC changes (decreasing nodal degree in the dorsal anterior cingulate cortex and increasing in other cingulate cortex regions) and behavioral improvement in their symptoms and substance use. There was also a significant positive association between the decreased nodal degree in regions of the dorsal cingulate cortex and a decrease in the score of the TAS-20 indicating difficulty in identifying feelings after psychotherapy.

CONCLUSION

In BPD, there is altered FC within the DMN and disruption in self-processing and emotion regulation. Psychotherapy may modify the DMN connectivity and that modification is associated with positive changes in BPD emotional symptoms.

Epistemic trust and unchanging personal narratives

Focusing on imagination and the social context in the generation of conviction narratives, we propose that these elements are dynamically related to one another, and crucially that it is the nature of this relationship that determines individuals' level of epistemic openness and capacity to respond adaptively to update their narratives in a way that increases the possibility of more successful decision-making.

Patient perspectives on non-response to psychotherapy for borderline personality disorder: a qualitative study

BACKGROUND

Despite increasing evidence for the effectiveness of psychotherapy for Borderline Personality Disorder (BPD), estimates show that approximately half of those in treatment do not clinically improve or reach reliable change criteria. There are limited qualitative descriptions of treatment factors associated with non-response from the perspectives of those struggling to improve.

METHOD

Eighteen people (72.2% female, mean age 29.4 (SD = 8)) with experience of receiving psychotherapeutic treatment for BPD were interviewed to obtain their perspectives on hindering factors in treatment and what may be helpful to reduce non-response. The data in this qualitative study was analysed thematically.

RESULTS

Four domains were created from the insights patients shared on non-response and what may be needed to mitigate it. The focus of Domain 1 was that therapy cannot be effective until two factors are in place. First, the patient needs sufficient safety and stability in their environment in order to face the challenges of therapy. Second, they need to be able to access therapy. Domain 2 described factors the patients themselves contribute. The themes in this domain were described as phases that need to be progressed through before therapy can be effective. These phases were ceasing denial that help is warranted and deserved, taking responsibility for behaviours that contribute to unwellness, and committing to the hard work that is required for change. Domain 3 described how the lack of a safe alliance and ruptures in the safety of the relationship with the therapist can contribute to non-response. Domain 4 was comprised of factors that patients identified as supportive of moving through the barriers to response. The first theme in this domain was prioritising the safety of the therapy relationship. The second theme was giving a clear diagnosis and taking a collaborative approach in sessions. The final theme described the importance of focusing on practical goals with the patient to create tangible life changes.

CONCLUSION

This study found that non-response is complex and multifaceted. First, it is clear that systems need to be in place to support access to adequate care and foster life stability. Second, considerable effort may be needed at the engagement phase of therapy to clarify expectations. Third, attention to specific interpersonal challenges between patients and therapists is an important focus. Finally, structured work to improve relationships and vocational outcomes is indicated.

Adolescence in lockdown: The protective role of mentalizing and epistemic trust

OBJECTIVE

Mentalizing is the ability to interpret one's own and others' behavior as driven by intentional mental states. Epistemic trust (openness to interpersonally transmitted information) has been associated with mentalizing. Balanced mentalizing abilities allow people to cope with external and internal stressors. Studies show that social isolation imposed by the COVID-19 pandemic was highly stressful for most people, especially for adolescents. Here we examine whether mentalizing and epistemic trust were protective factors in relation to emotional distress during the lockdown.

METHOD

A total of 131 nonclinical adolescents, aged between 12 and 18 years, were evaluated during the lockdown using the Reflective Functioning Questionnaire for Youth, Inventory of Parent and Peer Attachment, Perceived Stress Scale, and Difficulties in Emotion Regulation Scale.

RESULTS

Results from network analysis showed that epistemic trust and mentalizing were negatively associated with perceived stress and emotion dysregulation. Epistemic trust in fathers was associated with level of perceived stress, and epistemic trust in mothers with emotion dysregulation.

CONCLUSION

These findings suggest that epistemic trust and the capacity to mentalize were low in adolescents during lockdown, and this was associated with high levels of stress. However, robust levels of epistemic trust and mentalizing may have acted as protective factors that buffered individuals from the risk of emotional dysregulation during the lockdown.

Developing and Validating a Facial Emotion Recognition Task With Graded Intensity

Facial emotion recognition (FER) tasks are often digitally altered to vary expression intensity; however, such tasks have unknown psychometric properties. In these studies, an FER task was developed and validated-the Graded Emotional Face Task (GEFT)-which provided an opportunity to examine the psychometric properties of such tasks. Facial expressions were altered to produce five intensity levels for six emotions (e.g., 40% anger). In Study 1, 224 undergraduates viewed subsets of these faces and labeled the expressions. An item selection algorithm was used to maximize internal consistency and balance gender and ethnicity. In Study 2, 219 undergraduates completed the final GEFT and a multimethod battery of validity measures. Finally, in Study 3, 407 undergraduates oversampled for borderline personality disorder (BPD) completed the GEFT and a self-report BPD measure. Broad FER scales (e.g., overall anger) demonstrated evidence of reliability and validity; however, more specific subscales (e.g., 40% anger) had more variable psychometric properties. Notably, ceiling/floor effects appeared to decrease both internal consistency and limit external validity correlations. The findings are discussed from the perspective of measurement issues in the social cognition literature.

The role of emotional instability in borderline personality disorder: a systematic review

BACKGROUND

The emotional regulation process plays a pivotal role in daily-life functioning, modulating goal-directed and adaptive behavior. Conversely, altering this cognitive function can disrupt self-regulation and bring emotional dysregulation. Emotional instability could represent a core characteristic of BPD, also modulating the BPD symptom's onset. This systematic review aims to summarize the existing literature reporting the role of emotional instability in BPD to better define the role of the impairment of the emotional processes in the onset of the cognitive and behavioral symptoms of this complex mental disorder.

METHODS

MEDLINE, Scopus and Web of Science were independently searched for relevant studies. Eligible studies had to be identifiable through database searching, published and accessible. This systematic review was conducted according to PRISMA guidelines. The search period was from 2012 to 14 September 2022.

RESULTS

A pool of 120 studies was identified, out of which 11 met the selection criteria and were included. Overall, the studies confirm a relationship between emotional instability and borderline personality disorder.

CONCLUSIONS

The evidences retrieved seem to point out the role of the emotional impairment not only in worsening of the disorder, but could also be one of the risk factors for its onset.

Exploring and Deepening the Facets of Mentalizing: The Integration of Network and Factorial Analysis Approaches to Verify the Psychometric Properties of the Multidimensional Mentalizing Questionnaire (MMQ)

Mentalization is a complex and multifaceted trans-theoretical and trans-diagnostic construct that has found increasing application in the clinical context. This research aimed at deepening the psychometric properties of the Multidimensional Mentalizing Questionnaire (MMQ), a 33-item theoretically based self-report questionnaire allowing for a comprehensive assessment of mentalizing, by integrating factor analysis and network analysis approaches. A sample of 1640 participants (M_age = 33 years; SD = 13.28) was involved in the research. The six-factor structure was confirmed for the MMQ, and both the total and the subdimensions demonstrated good reliability. The network analysis has further enriched these results, showing the central role of the items attributable to Emotional Dysregulation or Reflexivity in influencing the network as well as the contribution of aspects related to Relational Discomfort in managing the flow of communication flow. Such findings may have useful clinical implications and emphasize the usefulness of the MMQ in both research and clinical practice.

Meta-analyses of the associations of mentalization and proxy variables with anxiety and internalizing problems

Mentalization, the high-order function of detecting and interpreting one's own and others' mental states, has gained interest in the fields of clinical and developmental psychopathology. However, little is known about mentalization's associations with anxiety and broader internalizing problems. Using the framework of the multidimensional model of mentalization, the aim of this meta-analysis was to quantify the strength of the association between mentalization and anxiety/internalizing problems and to identify potential moderators of this association. A systematic review of the literature led to the inclusion of 105 studies (N = 19,529) covering all age groups. The global effect analysis showed a small negative association between mentalization and the overall anxious and internalizing symptomatology (r = -0.095, p = .000). Various effect sizes were found for associations between mentalization and specific outcomes (unspecified anxiety, social anxiety, generalized anxiety, and internalizing problems). The methods of assessment of mentalization and anxiety moderated their association. Findings support the presence of modest impairments in the mentalizing capacities of anxious individuals, likely influenced by their vulnerability to stress and the context in which they mentalize. Further studies are needed to draw a clear profile of mentalizing capacities with regard to specific anxious and internalizing symptomatologies.

Understanding Men's Engagement and Disengagement When Seeking Support for Mental Health

Men are less likely to utilize health care services compared with women. When it comes to mental health, men have been reported to hold more reluctant attitudes toward engaging with mental health services. Current studies have predominantly been quantitative and focused on understanding effective strategies to promote men's engagement and why men may avoid help-seeking or may not seek help early; few studies exist of men's disengagement from services. Much of this research has been undertaken from the services' perspective. The study reported here attempts to gain better insight into the reasons men give for their disengagement from mental health services and what men say will reengage them back into the system. This research was a secondary analysis of data collected by a national survey conducted by Lived Experience Australia (LEA). Responses of 73 male consumers were gathered and analyzed. Analysis of the responses was split into two themes with associated subthemes: (1) Why men disengage: (1.1) Autonomy; (1.2) Professionalism; (1.3) Authenticity; and (1.4) Systemic Barriers; and (2) What will help men reengage: (2.1) Clinician-driven reconciliation, (2.2) Community and Peer Workers; and (2.3) Ease of reentry. Findings highlight strategies to prevent disengagement such as creating open and honest therapeutic environments and improving men's mental health literacy while providing care. Evidence-based approaches to reengage male consumers are suggested along with an emphasis on men's strong preferences for community-based mental health services and peer workers.

Pathways to antisocial behavior: a framework to improve diagnostics and tailor therapeutic interventions

The Antisocial Personality Disorder (ASPD), and antisocial behavior (ASB) in general, is associated with significant impact on individuals themselves, their environment, and society. Although various interventions show promising results, no evidence-based treatments are available for individuals with ASPD. Therefore, making informed choices about which treatment can be applied to an individual patient is complicated. Furthermore, contradictory findings on therapy effectiveness and underlying factors of ASB, such as cognitive impairments and personality traits, fuel the debate whether the conceptualization of ASPD in the DSM-5 is accurate and whether this population can be seen as homogeneous. A conceptual framework, based on the reciprocal altruism theory, is presented in which we propose different pathways to ASB. These pathways suggest underlying dynamics of ASB and provide an explanation for previous contradictory research outcomes. This framework is intended to serve as a clinically relevant model that provides directions for improving diagnostics and matching treatments to underlying dynamics in the antisocial population.