Patient characteristics of completion and dropout of mentalization-based treatment for adolescents with conduct disorder.

Introduction: Conduct disorder (CD) is a severe mental disorder in youth. Yet, providing psychological interventions for adolescents with CD is challenging. This patient group is often characterized by risk factors for therapy dropout such as, e.g., CD symptoms and being in middle adolescence. On the other hand, little is known about characteristics of adolescents with CD who complete treatment. To gain more insight into what might become a successful therapy with adolescents with CD, this study explores baseline characteristics and drop-out occurrence in patients with CD referred to mentalization-based treatment for adolescents with CD (MBT-CD). More specifically, this study aims at identifying clusters of adolescent patients based on age, CD symptom severity and personality pathology at the beginning of treatment which may have come along with a higher or lower dropout occurrence. Methods: Following implications of an elbow plot, a 3-means cluster-analysis was conducted on self-report baseline data of N = 32 adolescents with CD (n = 11 dropouts, n = 21 completers) who participated in a feasibility study on MBT-CD. Additionally, in an exploratory stepwise logistic regression, variables were explored as potential predictors of dropout. Results: Cluster 1 consisted of n = 14 adolescents, of whom n = 8 (57%) dropped out. Cluster 2 consisted of n = 5 adolescents of whom 1 (20%) dropped out. Cluster 3 consisted of N = 13 adolescents, of whom only n = 2 (15%) dropped out. Cluster 2 showed descriptively the highest CD symptom severity. While adolescents in Clusters 1 and 3 showed in part similarities in CD symptom severity, personality pathology was descriptively markedly higher in Cluster 1. In the stepwise logistic regression, only intimacy personality pathology was identified as potential predictor for dropout. Discussion: This study's exploratory findings point to different types of adolescents with CD coming along with different chances for therapists to conduct a (successful) psychotherapy. Herein, low personality functioning in the intimacy domain, rather than CD symptoms as aggressiveness, may play a crucial role. While findings are limited by the small sample size, they may be able to shed increasing light on conducting (successful) psychotherapy with a scarcely researched patient group.

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.

Within- and between-session changes of in-session reflective functioning of mothers in dyadic parent-infant psychotherapy.

This study investigated if in-session reflective functioning (RF) of mothers improved between and within sessions of brief dyadic focused parent-infant psychotherapy (fPIP) for the treatment of regulatory disorders in infants.In-session RF was coded for 44 therapy sessions from N = 11 mothers randomly selected from a RCT on the efficacy of fPIP as part of secondary analyses. A new rating system distinguished self-focused and child-focused in-session RF. Cumulative ordinal regression models were applied to analyze the dynamics of in-session RF within and across sessions, controlling for word count of each statement.While in-session RF improved significantly within sessions, between-session RF improved significantly only in the second session compared to the first with a significant decrease observed in the last session. Child-focused in-session RF was significantly lower than self-focused in-session RF at the beginning of the sessions but improved significantly stronger than self-focused in-session RF during sessions.In-session RF (particularly in child-focused statements) can be regarded as a dynamic change process relevant within each session of dyadic fPIP. Improvements made on a session-by-session basis may not be maintained until the next session. Implications for practitioners and in-session RF research are discussed.

["IThink it's Good that they Choose who they want to be Stroked by" -The Support Quality of Animal-BasedTherapy]. / "Ich finde es gut, dass sie sich aussuchen, von wem sie gestreichelt werden wollen" ­ Die Unterstützungsqualität tiergestützter Therapie.

For Adolescents with personality impairments it's often difficult to accept therapy offers. Personality impairment may be preceded by (early childhood) trauma, which undermines trust in others.Thus, adolescents with traumatic experience often have limited motivation to start psychotherapy, also due to the greater need for autonomy and the process of detachment in this age phase. However, adolescence is a particularly sensitive period, as personality impairments may consolidate and personality disorders (PD) develop. To address low trust and lowmotivation in adolescents with high risk for or already full PD an animal-assisted group therapy adjunct to individual mentalization-based therapy was developed and piloted. Two groups with a total of eleven patients each were conducted, four of whom agreed to talk about their experiences with animal-assisted therapy in an interview after completion of therapy. Interviews were analyzed qualitatively and evaluated with regard to the aspects of what the adolescents liked and disliked, what expectationsweremet or unmet, andwhat effects the adjunct intervention had on the adolescents' therapeutic success.The categorized statements are discussed related to the theories of human-animal interaction according to Hediger et al. (2019) and a new hypothesis about animals as teambuilding catalysts could be established. In sum, alpacas were perceived suitable as therapy animals for adolescents with personality impairments.

The relationship between epistemic stance, mentalizing, paranoid distress and conspiracy mentality: an empirical investigation.

Epistemic stance, comprising epistemic trust, mistrust, and credulity, and the closely related construct of mentalizing have been related to paranoid ideation and conspiracy mentality. All phenomena are common in the general population and may become clinically and societally relevant at an extreme expression by influencing an individual's positioning towards socially transmitted information possibly as far as complete social detachment or attachment to extremist views. Herein, an individual's experienced distress may play an important role, which has however largely been neglected in empirical research. Thus, this study aims to empirically investigate the effect of epistemic stance on a clinically relevant aspect of paranoid ideation, namely paranoid distress. We assume that epistemic stance will be associated with paranoid distress, but that this association will be mediated by mentalizing. Moreover, we assume that epistemic stance will be indirectly associated with conspiracy thinking via paranoid distress. Data of 595 participants (mean age = 43.05; SD = 13.87; female = 48.32%, male = 51.18%, diverse = 0.51%) were collected via self-report questionnaires through an online-based cross-sectional study. Structural equation modeling was performed for data analysis. As expected, epistemic mistrust was associated with paranoid distress via mentalizing deficits. Unexpectedly, epistemic trust was associated with more paranoid distress. Indirectly, epistemic trust was associated with conspiracy mentality via paranoid distress. Findings partially confirmed the hypothesized associations. Mentalizing may be a target for reducing distress associated with a distrusting epistemic stance. Epistemically trusting individuals with high paranoid distress may turn to conspiracy theories for regulation.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): a feasibility study.

Conduct disorder (CD) is a common psychiatric disorder in youth characterized by persisting norm-violating or aggressive behavior. Considering high individual and societal burden, feasible and effective psychotherapeutic treatment is desirable. Yet, treatments and research in this patient group are scarce. This study investigates the feasibility of mentalization-based treatment for adolescents with CD (MBT-CD) in terms of acceptability of MBT-CD and scientific assessments by participants as well as necessary organizational resources to conduct a consecutive randomized controlled trial (RCT). Recruitment, adherence and treatment session numbers were descriptively analyzed. Treatment evaluation interviews were qualitatively analyzed. A subset of sessions of therapists without prior MBT experience was rated for MBT adherence. Quantitative data were used to plan a consecutive RCT. Pre to post treatment changes in diagnosis and self-reported aggression, mentalizing and personality functioning were preliminarily analyzed. N = 45 adolescents with CD were recruited. 43% dropped out. Acceptance of scientific assessments was somewhat lower than therapy adherence (questionnaires filled out by ~ 80% of adolescents in treatment), and low at follow-up (25% of treatment completers). Mean session number was 30.3. Most treatment completers were satisfied with MBT-CD. Referrals mainly came from child and youth services and psychiatry. Nine of 16 sessions rated for MBT adherence were adherent. A priori sample size estimation for a prospective RCT with a drop-out rate of 43% yielded a sample of N = 158 to detect an effect f = .15 with 80% power in a repeated measures ANOVA. Pre-post analyses revealed diagnostic improvement in 68%. Of self-reported data, empathy pathology improved. Findings provide a sound basis for a consecutive feasibility and pilot RCT. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT02988453, November 30, 2016, https://clinicaltrials.gov/ct2/show/NCT02988453.

Enhancing mentalization by specific interventions within mentalization-based treatment of adolescents with conduct disorder.

Objective: Mentalization is discussed as a mechanism of change in psychotherapy due to its positive effects on psychological functioning. In order to specifically apply mentalization-based interventions, a better understanding of the relationship between interventions and in-session mentalization is needed. The study aimed to explore the association between interventions and effective mentalizing. Method: Fifteen therapy sessions of three therapies with male adolescents with conduct disorder were transcribed and rated with the Reflective Functioning (RF) Scale and a newly developed Mentalization-based Treatment (MBT) intervention coding manual. The coded interventions were categorized into intervention levels according to the MBT manual. Fisher's exact tests were performed to test differences in frequencies of interventions in high-RF sequences (RF score ≥ 4) compared with remaining therapy sequences (RF score ≤ 3). Results: Specific MBT interventions such as demand questions, affectelaboration, empathic validation, change of subject, challenge, patienttherapist relation and mentalizing for the patient were related to effective mentalizing. Moreover, intervention levels such as supportive & empathic, basic- mentalizing & affect mode and relational mentalizing were positively associated with effective mentalizing. Conclusion: MBT interventions seem to promote effective mentalizing at various intervention levels. Interventions that enhance effective mentalizing seem to be patient specific. In line with MBT theory, their effect on effective mentalizing might depend on various variables, such as the patients' arousal and pre-mentalizing mode.

Improving working relationships with families in German early childhood interventions home visitors: a quasi-experimental training study.

BACKGROUND: Home visitation services within German Early Childhood Interventions (ECI) for families with a child aged 0-3 are mainly provided by frontline pediatric nurses and family midwifes. Home visitors are often challenged by difficult interactions with families. Mentalizing, the ability to understand mental states of oneself and others, is a key skill for building effective working relationships, which in turn positively affect intervention outcomes. The aim of this study was to investigate if a mentalizing skills training offered to home visitors active in German ECI contributes to continued professional development. We investigated, whether the training positively affected the quality of the working relationships with families as well as home visitors' empathy, self-efficacy, and mentalizing. METHODS: To test the effects of a single day mentalizing skills training on the working relationship in N = 73 ECI home visitors, we used a quasi-experimental design with repeated measures (T0, T1, T2, T3) across seven weeks in order to assess immediate change from baseline (T0) after the training (T2) and stability of changes at follow up (T3). A literature-based intervention was implemented before the training to estimate possible repeated measurement and expectational effects (T1). Primary outcome was the quality of the working relationship experienced by the home visitors. Secondary outcome criteria were empathy, work-related self-efficacy, self-reported and observer-rated mentalizing. RESULTS: Significant positive change in the working relationship quality was observed at T2 and at T3. Results on the secondary outcomes were less consistent, with data indicating improvement in empathy and increase on some but not all components of mentalizing. CONCLUSIONS: This study provides preliminary evidence that brief mentalizing skills trainings may be an effective method for continuous professional qualification in frontline ECI home visitors who afterwards, experience better working relationships with families. Thus, training participation may positively impact efficacy and implementation of home visitations in ECI.

[Bifocal perspective in the work with families with mentally ill parents]. / Bifokale Perspektive in der Arbeit mit Familien mit psychisch erkrankten Eltern: Training zur Verbesserung von Einstellungen, Wissen und Fertigkeiten für medizinische Fachkräfte.

BACKGROUND: Mentally ill parents pose a risk factor for the transgenerational transmission of mental disorders. Contemporary psychiatry mainly focuses on the individual and patients are not always recognized as being parents. OBJECTIVE: The development and evaluation of a training program for mental health professionals to support a family orientation in psychiatric treatment by using a bifocal perspective, which keeps an eye on the index patient and the family with a focus especially on children, are presented. METHODS: In order to establish the bifocal perspective in attitudes, knowledge and skills, a half-day training program, consisting of a lecture and a seminar was developed. This was carried out as part of the Children of Mentally Ill Parents -Research Network (CHIMPS-NET) consortium at seven locations in Germany in the respective adult, pediatric and adolescent departments of psychiatry. The needs were evaluated before the training using an online questionnaire. The implementation was accompanied by a qualitative analysis of memory protocols of the trainers. RESULTS AND DISCUSSION: The training could be successfully carried out with 120 participants, whereby the target of a comprehensive training of the complete personnel across occupational groups could not be realized, also partly due to the pandemic, and the exercising elements of training could not all be utilized. The evaluation of the questionnaire, which was completed by approximately 50% of the participants showed that the group of participating psychologists and physicians already had a strong family orientation. The qualitative analysis of protocols from all locations documented a strong need for networking across institutions and clear standard procedures, e.g. in dealing with child maltreatment.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): protocol of a feasibility and pilot study.

BACKGROUND: Conduct disorder (CD) is a complex mental disorder characterized by severe rule-breaking and aggressive behavior. While studies have shown that several therapeutic interventions are effective in treating CD symptoms, researchers call for treatments based on etiological knowledge and potential patho-mechanisms. Mentalization-based treatment (MBT) may represent such a treatment approach: Studies have shown that individuals with CD show mentalizing deficits and that mentalizing might represent a protective factor against the development of the disorder. As MBT focuses on the understanding of social behavior in terms of mental states, fostering mentalizing might help CD individuals to (re)gain an adaptive way of coping with negative emotions especially in social interactions and thus reduce aggressive behavior. For this purpose, MBT was adapted for adolescents with CD (MBT-CD). This is a protocol of a feasibility and pilot study to inform the planning of a prospective RCT. The primary aim is to estimate the feasibility of an RCT based on the acceptability of the intervention and the scientific assessments by CD individuals and their families indicated by quantitative and qualitative data, as well as based on necessary organizational resources to conduct an RCT. The secondary aim is to investigate the course of symptom severity and mentalizing skills. METHODS: The bi-center study is carried out in two outpatient settings associated with university hospitals (Heidelberg and Mainz) in Germany. Adolescents aged between 11 and 18 years with a CD or oppositional defiant disorder (ODD) diagnosis are included. Participants receive MBT-CD for 6 to 12 months. The primary outcome of the feasibility study (e.g., recruitment and adherence rates) will be descriptively analyzed. Multilevel modeling will be used to investigate secondary outcome data. DISCUSSION: Fostering the capacity to mentalize social interactions triggering non-mentalized, aggressive behavior might help CD individuals to behave more adaptively. The feasibility trial is essential for gathering information on how to properly conduct MBT-CD including appropriate scientific assessments in this patient group, in order to subsequently investigate the effectiveness of MBT-CD in an RCT. TRIAL REGISTRATION: ClinicalTrials.gov , NCT02988453 . November 30, 2016 SOURCES OF MONETARY SUPPORT: Dietmar Hopp Stiftung, Heidehof Stiftung RECRUITMENT STATUS: Recruitment complete and intervention complete, follow-up assessments ongoing (Heidelberg). Recruitment and assessments ongoing (Mainz). PRIMARY SPONSOR, PRINCIPAL INVESTIGATOR, AND LEAD INVESTIGATOR IN HEIDELBERG: Svenja Taubner is responsible for the design and conduct of MBT-CD intervention and feasibility and pilot study, preparation of protocol and revisions, and publication of study results. SECONDARY SPONSOR AND LEAD INVESTIGATOR IN MAINZ: Esther Sobanski is responsible for the recruitment and data collection in the collaborating center Mainz RECRUITMENT COUNTRY: Germany HEALTH CONDITION STUDIED: Conduct disorder, oppositional defiant disorder INTERVENTION: Mentalization-based treatment for conduct disorder (MBT-CD): MBT-CD is an adaptation of MBT for Borderline Personality Disorder. This manualized psychodynamic psychotherapy focuses on increasing mentalizing, i.e., the ability to understand behavior in terms of mental states, in patients. MBT-CD includes weekly individual sessions with the patient and monthly family sessions. KEY INCLUSION AND EXCLUSION CRITERIA: Included are adolescent individuals with a diagnosis of conduct disorder or oppositional defiant disorder aged between 11 and 18 years. STUDY TYPE: Feasibility and pilot study (single-group) DATE OF FIRST ENROLLMENT: 19.01.2017 STUDY STATUS: The trial is currently in the follow-up assessment phase in Heidelberg and in the recruitment and treatment phase in Mainz. PRIMARY OUTCOMES: Acceptability of MBT-CD intervention (as indicated by recruitment rates, completion rates, drop-out rates, treatment duration, oral evaluation), acceptability of scientific assessments (as indicated by adherence, missing data, oral evaluation), and necessary organizational resources (scientific personnel, recruitment networks, MBT-CD training and supervision) to estimate feasibility of an RCT SECONDARY OUTCOMES: Adolescents' symptom severity and mentalizing ability PROTOCOL VERSION: 20.08.2020, version 1.0.

[What Did You Like About the Therapy? - A Qualitative Study on the Evaluation of Mentalization-Based Treatment for Adolescents with Conduct Disorder]. / Was hat dir an der Therapie gefallen? ­ Eine qualitative Studie zur Evaluation der Mentalisierungsbasierten Therapie für Jugendliche mit Störungen des Sozialverhaltens.

Psychotherapeutic treatment for adolescents with conduct disorder (CD) is considered difficult for various reasons. On the one hand, patients frequently lack psychological strain, and striving for autonomy is part of typical adolescent development. On the other hand, therapists can react aversively to delinquent and violent behavior, and insufficient psychological models explaining aetiology and maintenance of symptoms can impede treatment of adolescents with CD. Mentalization-Based Therapy for adolescents with CD (MBT-CD) was developed with the aim of addressing these difficulties and improving psychotherapeutic treatment for this patient group. MBT-CD focuses on the promotion of the adolescents' autonomy by increasing their scope of action via an improvement of mentalizing ability. The aim of this qualitative study is to investigate the acceptance of MBT-CD by the adolescents in terms of their experience with MBT-CD and thus obtain information about aspects which enhance therapy motivation for this group of patients. For this purpose, we conducted semi-structured interviews with twelve adolescents after completion of therapy assessing their subjective therapy evaluation. Qualitative content analysis was used to analyze the data. The results show both helpful and hindering aspects of the mentalization-based interventions. In addition, the monthly family sessions included in the therapy were regarded as important. Adolescents also regarded emotion regulation strategies as helpful. Implications for the treatment of adolescents with CD are discussed.