The influence of attachment style on support and feedback seeking and depression severity among mothers during the COVID-19 pandemic.

OBJECTIVES: The ways that people seek support during times of stress influence their mental health outcomes, including depression. Insecure attachment is a risk factor for depression and may also interfere with adaptive support and feedback-seeking behaviour during stress. The purpose of the present study was to test theorized associations between insecure attachment, support and feedback seeking, and changes in depression symptoms over 1 year, in a sample of mothers of school-age children in the context of stress elicited by the COVID-19 pandemic. METHODS: Participants (N = 70 mothers) completed self-report measures of anxious and avoidant attachment and depression severity at baseline in spring 2020 and then completed measures of past-year engagement in direct and indirect support seeking and excessive reassurance seeking (ERS), preference for negative feedback, and depression severity at a follow-up assessment in summer 2021. RESULTS: Greater attachment anxiety at baseline predicted more frequent direct support seeking, indirect support seeking, and ERS during the 1-year follow-up period. In turn, greater indirect support seeking predicted greater increases in depression from baseline to follow-up. Greater attachment avoidance at baseline predicted less direct support seeking during the 1-year follow-up period. Greater attachment avoidance at baseline also predicted depression severity at follow-up, particularly among mothers with moderate to high levels of attachment anxiety, although none of the examined support and feedback-seeking behaviours mediated this association. CONCLUSIONS: These results provide support for the role of activated attachment systems in determining support and feedback-seeking behaviour during stress, as well as the role of support and feedback-seeking behaviour in the maintenance and exacerbation of depression.

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

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

Be My Safe Haven: Parent-Child Relationships and Emotional Health During COVID-19.

OBJECTIVE: Since March 2020, millions of children have been confined to their homes and restricted from in-person activities, radically changing the dynamics of parent-child relationships. This study examines the association between coronavirus disease 2019 (COVID-19) impact and the mental health of parents and school-aged children; specifically, whether qualities of the parent-child relationship moderated the relationship between parents' emotional health (EH) and children's emotional and behavioral health (EBH). METHODS: Data from this Internet-based study of a community sample were collected in March-May 2020. Parents (N = 158, 92.4% White, 96.2% female) reported on COVID-19 impacts, their own EH, perceptions of their relationship with their eldest child between 6 and 12 years-old, and the EBH of that child. RESULTS: Responses to questions about COVID-19 impact were assigned weighted values and used to create a COVID-19 impact scale. Hierarchical linear regressions revealed that greater COVID-19 impact was associated with greater parents' EH issues only, and parents' EH was a significant positive predictor of children's EBH. Positive qualities and conflict in the parent-child relationship moderated the link between parents' and children's EH. At higher levels of relationship conflict and lower levels of positivity, there were stronger positive associations between parents' and children's EH. Parent-child relationship quality did not moderate the association between parents' EH and children's behavioral health (BH). CONCLUSIONS: These cross-sectional study results suggest that beyond focusing on symptom management, families may benefit from supports targeting the parent-child relationship. Insights and implications for practitioners are discussed.

A scoping review of machine learning in psychotherapy research.

Machine learning (ML) offers robust statistical and probabilistic techniques that can help to make sense of large amounts of data. This scoping review paper aims to broadly explore the nature of research activity using ML in the context of psychological talk therapies, highlighting the scope of current methods and considerations for clinical practice and directions for future research. Using a systematic search methodology, fifty-one studies were identified. A narrative synthesis indicates two types of studies, those who developed and tested an ML model (k=44), and those who reported on the feasibility of a particular treatment tool that uses an ML algorithm (k=7). Most model development studies used supervised learning techniques to classify or predict labeled treatment process or outcome data, whereas others used unsupervised techniques to identify clusters in the unlabeled patient or treatment data. Overall, the current applications of ML in psychotherapy research demonstrated a range of possible benefits for indications of treatment process, adherence, therapist skills and treatment response prediction, as well as ways to accelerate research through automated behavioral or linguistic process coding. Given the novelty and potential of this research field, these proof-of-concept studies are encouraging, however, do not necessarily translate to improved clinical practice (yet).

[From Pretending to Play to Playing Pretend: The Role of Epistemic Trust in Mentalization-Based Therapy with Children]. / Vom Tun, als würde man spielen, zum Spielen, als würde man tun: Die Rolle epistemischen Vertrauens in der Mentalisierungsbasierten Therapie mit Kindern.

From Pretending to Play to Playing Pretend: The Role of Epistemic Trust in Mentalization-Based Therapy with Children Although all forms of psychotherapy encourage the patient to focus on their mental states and those of other people, it is a distinguishing characteristic of Mentalization-Based Therapy (MBT; Fonagy u. Bateman, 2006; Bateman u. Fonagy, 2016) to place such focus at the center of treatment. In MBT-Child there is the added element of play, which is considered a primary vehicle for enhancing mentalization (Midgley, Ensink, Lindqvist, Malberg, Muller, 2017). However, pre-mentalizing modes during play are developmentally normative in children. Thus, it can be difficult to distinguish between play as a goal of treatment, and the psychic equivalence and pretend modes. This paper presents some thoughts about how we can unravel the relationships between restoring mentalizing and the process by which children in therapy "learn to play". We begin by introducing the theoretical principles that underlie MBT and MBT-C, with particular focus on defining the pre-mentalizing modes. Then, we discuss recent innovations in thinking about the role of epistemic trust in psychotherapy and present a possible use of this concept in understanding pre-mentalizing modes during playing. We suggest ways in which mentalization-based techniques used when children are in pre-mentalizing modes may restore epistemic trust and act as a mechanism of change in child psychotherapy, opening up the child's capacity to both play and mentalize in relation to their social environment. Finally, we present a clinical case of a mentalization focused treatment with a 9-year old child to illustrate our views.

Group attachment-based intervention: trauma-informed care for families with adverse childhood experiences.

This article outlines the main premises of an innovative trauma-informed intervention, group attachment-based intervention, specifically developed to target vulnerable families with infants and toddlers, living in one of the poorest urban counties in the nation. It also reports on the trauma-relevant characteristics of 60 families entering a clinical trial to study the effectiveness of Group Attachment-Based Intervention. Initial survey results revealed high levels of neglect, abuse, and household dysfunction in mothers' histories (77% reported ≥4 adverse childhood experiences, with more than 90% reporting 2 or more current toxic stressors, including poverty, obesity, domestic and community violence, and homelessness).

Looking from the outside in: the use of video in attachment-based interventions.

This paper provides an account of multiple potential benefits of using video in clinical interventions designed to promote change in parent-child attachment relationships. The power of video to provide a unique perspective on parents' ways of thinking and feeling about their own behavior and that of their child will be discussed in terms of current attachment-based interventions using video either as the main component of the treatment or in addition to a more comprehensive treatment protocol. Interventions also range from those that use micro-analytic as compared to more global units of analyses, and there are potential bridges to be made with neuro-scientific research findings. In addition, this paper provides a clinical illustration of the utility of showing parents vignettes of video-filmed observations of parent-child interactions from the Group Attachment Based Intervention (GABI) for vulnerable families. Emphasis is placed on the motivational force arising from seeing (and hearing) oneself in interaction with one's child on video, thus serving as a powerful catalyst for reflective functioning and updating one's frame of reference for how to think, feel and behave with one's child.

Facilitative interpersonal skills are relevant in child therapy too, so why don't we measure them?

One of the consistent findings from psychotherapy process research has been the impact of therapist effects on patient change and the therapeutic alliance. The Facilitative Interpersonal Skills (FIS) paradigm is a task in which participants respond to standardized videos of actors playing patients in interpersonally challenging moments as if they were the therapist, which was designed to assess therapist effects. Participants' video recorded responses are coded for eight skills: verbal fluency, emotional expressiveness, warmth/acceptance/ understanding, empathy, persuasiveness, hope/positive expectations, alliance-bond capacity, and rupture-repair responsiveness. Performance-based procedures like the FIS minimize self-report bias and systematically control for client-related variability while maintaining strong clinical relevance. Research has shown that therapist FIS predicts the quality of the therapeutic alliance and outcome in adult psychotherapy. This paper describes the development and first adaptation of the FIS task using child and adolescent patients as the stimuli, and reports findings from a pilot study testing the reliability. The FIS-Child (FIS-C) task was administered to 10 therapists with a range of clinical backgrounds. Participants also completed the original FIS task and self-report measures of their empathy, social skills, and playfulness. Adequate interrater reliability was achieved on the FIS-C. There were no significant differences between participants' ratings on the FIS-C compared to the original FIS, although there were minor differences in the correlations between the FISC and self-report measures compared to the original FIS. Findings support moving forward with utilizing the FIS-C to empirically study therapist effects that may be common factors across treatment models.

Containing the Anxieties of Children, Parents and Families from a Distance During the Coronavirus Pandemic.

The coronavirus pandemic and the move to teletherapy has created uncertainty among both clinicians and patients. As therapists who work with children, we have heard from parents who are desperate for support and advice about how to respond to their children's behavioral changes, as well as those who feel too overwhelmed to continue their children's sessions at the moment and want to take a break from treatment. We have had to rethink the frame in concrete ways, reimagine how to play, and renegotiate parameters around confidentiality. At a time when fear and uncertainty make mentalizing difficult, the hallmarks of a mentalizing approach-curiosity and flexibility-are most critical. This paper will describe how the Mentalization-Based Treatment for Children (MBT-C) model offers a framework for an integrative approach that can inform treatment via teletherapy, so that clinicians can continue supporting young people and their families through this period. We will begin by describing how the mentalizing stance, particularly an awareness of our own mentalizing capacities in the moment, has become more important than ever. Ways in which clinicians maintain their mentalizing in the face of the mentalizing breakdowns will be also discussed. Finally, we illustrate with clinical vignettes how the developmental levels of mentalizing-attention control, emotion regulation, and explicit mentalizing-can inform the structure, techniques and interventions in teletherapy with children and parents.

Patients' Adult Attachment Interview classification and their experience of the therapeutic relationship: are they associated?

In the last decade of his career, Jeremy Safran became increasingly interested in investigating the ways in which attachment representations influence the therapeutic relationship. In this paper, we test such influence in a sample of thirty outpatients who received Brief Relational Therapy by comparing their independently coded pre-treatment Adult Attachment Interview (AAI) with their narratives in a post-treatment interview about the relationship with the therapist (the Patient Relationship Interview at Termination, PRI-T). The PRI-T was coded with the following three measures: i) The Patient Attachment to Therapist Rating Scale (PAT-RS), which assesses the quality of the patient's attachment relationship to the therapist; ii) the Coherence scale from the AAI, adapted for use on the PRI-T; and iii) the Patient Attachment Classification System (PACS), which measures generalized differences in how individuals convey their experiences and feelings. Results suggest that patients' AAI predicts how they experience, represent, and communicate about the therapeutic relationship at the end of treatment, as shown by the PAT-RS, the Coherence scale adapted for use on the PRI-T, and the PACS applied to the PRI-T. These findings lend support to Safran and others' hypothesis that patients' AAI-status plays a role in patients' representations of the relationship with the therapist.

Adverse Childhood Experiences (ACEs) questionnaire and Adult Attachment Interview (AAI): implications for parent child relationships.

Although Adverse Childhood Experiences (ACEs) are linked to increased health problems and risk behaviors in adulthood, there are no studies on the association between ACEs and adults' states of mind regarding their early childhood attachments, loss, and trauma experiences. To validate the ACEs questions, we analyzed the association between ACEs and emotional support indicators and Adult Attachment Interview (AAI) classifications in terms of unresolved mourning regarding past loss or trauma and discordant states of mind in cannot classify (U/CC) interviews. Seventy-five urban women (41 clinical and 34 community) completed a questionnaire on ACEs, which included 10 categories of abuse, neglect, and household dysfunction, in addition to emotional support. Internal psychological processes or states of mind concerning attachment were assessed using the AAI. ACE responses were internally consistent (Cronbach's α=.88). In the clinical sample, 84% reported≥4 ACEs compared to 27% among the community sample. AAIs judged U/CC occurred in 76% of the clinical sample compared to 9% in the community sample. When ACEs were≥4, 65% of AAIs were classified U/CC. Absence of emotional support in the ACEs questionnaire was associated with 72% of AAIs being classified U/CC. As the number of ACEs and the lack of emotional support increases so too does the probability of AAIs being classified as U/CC. Findings provide rationale for including ACEs questions in pediatric screening protocols to identify and offer treatment reducing the intergenerational transmission of risk associated with problematic parenting.