Expert clinicians' prototypes of an adolescent treatment: Common and unique factors among four treatment models.

To investigate (1) whether expert clinicians within psychodynamic therapy (PDT), mentalization-based treatment (MBT), cognitive-behavioral therapy (CBT), and interpersonal psychotherapy (IPT) agree on the essential adolescent psychotherapy processes using the Adolescent Psychotherapy Q-Set (APQ); (2) whether these four session prototypes can be empirically distinguished; and (3) whether mentalization is a shared component in expert clinicians' conceptualizations of these four treatment models.Thirty-nine raters with expertize in PDT, MBT, CBT, and IPT provided ratings of the 100 APQ items to characterize a prototypical session that adheres to the principles of their treatment model. A Q-factor analysis with varimax rotation was conducted.Expert clinicians reached a high level of agreement on their respective session prototypes, which loaded onto five independent factors. The PDT session prototype straddled two different factors, suggesting more variability in PDT expert clinicians' understanding of PDT process for adolescents than in the views of the expert clinicians representing the other treatment models. Mentalization process was shared among all four session prototypes; however, the correlation between the CBT and IPT session prototypes remained significant after controlling for the MBT session prototype.Researchers can now assess adherence to four adolescent treatments and identify change processes beyond these labels.

Representations of attachment security, attachment avoidance, and gender in Ugandan children.

Researchers returned to the home of Mary Ainsworth's original attachment study to explore the contributions of Ugandan children's representations of attachment interactions with their caregivers to their perceptions about gender. Researchers administered the Attachment Story-Completion Task (ASCT) and applied three attachment narrative coding systems and a gender stereotypes typology to the ASCT stories of 51 Ugandan children ages 5-7. Nine attachment narrative variables were applied to the children's responses to a series of five attachment story stems told using a family of dolls. The narratives emerging from the children's responses to these story stems were also coded independently for 14 masculine and 14 feminine gender stereotypes. Empathic relations among the dolls and narrative coherence were positively correlated with counterstereotypical gender representations only in girls. Attachment representations of a rejecting father were positively correlated with stereotypical gender representations only in boys. Representations of attachment avoidance were negatively correlated with counterstereotypical gender representations in both boys and girls. The findings suggested two different trajectories for the development of gender representation flexibility in boys and girls. This study contextualizes these findings against the backdrop of a country with rigid sex roles and a fast-growing child population.

Interaction structures as predictors of outcome in a naturalistic study of psychodynamic child psychotherapy.

Objective: The first aim of this study was to identify interaction structures (IS), which refer to clusters of items characterizing the course of psychotherapy in terms of reciprocal interaction patterns between the therapist and the child, secondly to assess their trends over the course of treatment, and finally investigate which IS predict outcome in long-term psychodynamic child psychotherapy.Method: The sample included 52 children with externalizing and internalizing problems. 192 sessions were rated with the use of the Child Psychotherapy Q-Set (CPQ). Outcome was assessed with the Child Behavior Checklist (CBCL) Total Problems, and Children's Global Assessment Scale (CGAS).Results: A principal components analysis resulted in four IS, theoretically named Therapeutic Alliance, Children's Emotion Expression, Child -Centered Technique and Psychodynamic Technique. Multilevel Modeling (MLM) analyses indicated significant linear growth on Psychodynamic Technique. Multiple regression analyses indicated that Psychodynamic Technique positively predicted changes on CBCL Total Problems and CGAS. In contrast, Child-Centered technique negatively predicted change on CBCL Total Problems, however follow up interaction analyses showed that externalizing children who received more Child-Centered technique showed more improvement on this scale.Discussion: Findings point to empirically derived components of psychodynamic child psychotherapy and provide preliminary answers about which aspects may facilitate change.

Expert clinicians' prototypes of an ideal child treatment in psychodynamic and cognitive-behavioral therapy: Is mentalization seen as a common process factor?

OBJECTIVE: To investigate (a) whether expert clinicians within psychodynamic therapy (PDT) and cognitive-behavioral therapy (CBT) agree on key features of child psychotherapy process using the Child Psychotherapy Process Q-Set (CPQ); (b) whether these two prototypes can be empirically distinguished; and (c) whether promoting mentalization (operationalized as reflective functioning [RF]) is a shared component of the way expert clinicians conceptualize these two treatment models. METHOD: Thirty-one raters with expertise in PDT, CBT, and RF provided ratings of the 100 CPQ items to describe an ideal prototype session that adheres to the principles of their treatment model. Two Q-factor analyses with varimax rotation were conducted. RESULTS: Expert clinicians reached a high level of agreement on their respective PDT and CBT prototypes. These prototypes loaded onto two independent factors. The RF process prototype loaded onto both factors. CONCLUSIONS: From the theoretical perspective of expert clinicians representing PDT and CBT, a focus on RF appears to be a common process factor in the way both treatment models are conceptualized. The CPQ can also be a useful instrument in teaching psychotherapy process from different theoretical perspectives and training future clinicians in their application. Future researchers can use these prototypes to explore process in actual sessions.

The relation between prototypical processes and psychological distress in psychodynamic therapy of five inpatients with borderline personality disorder.

UNLABELLED: Five inpatients with borderline personality disorder (BPD) participated in 6 months of three times per week psychodynamic therapy (PDT). Patients completed a measure of psychological distress every week. A total of 127 sessions were audiotaped and coded using the psychotherapy process Q-set (PQS) and correlated with PQS prototypes of five treatment models-PDT, cognitive-behaviour therapy (CBT), interpersonal therapy, transference focused psychotherapy and dialectical behaviour therapy. Prototypical CBT process was most prevalent in three of the five PDT-labelled treatments. Prototypical PDT process significantly decreased over time in three of the five treatments. Prototypical process correlations with time were inversely proportional to prototypical process correlations with distress levels. In a multiple regression model that included all five prototypical process correlations across these three treatments, CBT and transference focused psychotherapy predicted distress reduction, whereas PDT predicted increases in distress. PQS items most negatively correlated with distress included the therapist's emphasis on feelings, empathic attunement and control over the interaction. Discussion of dreams or fantasies and therapist aloofness were most positively correlated with distress. An effective PDT treatment model for severely disturbed BPD inpatients requires technical flexibility to supplement CBT processes such as control over the interaction that can structure intense interpersonal dysregulation and stabilize distress. KEY PRACTITIONER MESSAGE: Practitioners and their patients sense which prototypical processes to increase or decrease over time to reduce patients' distress. An effective PDT treatment model for severely disturbed BPD patients needs to integrate and encourage the emergence of empathically attuned interactions in the context of a highly structured therapy experience. Practitioners need to be flexible enough to change intervention strategies when they seem to be increasing distress in severely disturbed BPD patients.

The Efficacy of Two Group Interventions on Mental Representations, Attachment Security, and Trauma Symptoms in Ethnically and Socioeconomically Minoritized Young Adolescents in an Urban Middle School.

Symptoms resulting from childhood trauma can negatively impact socioemotional well-being and school performance during early adolescence unless positive changes in attachment security and mental representations of significant relationships occur. A sample of 109 eighth grade urban students were randomly assigned to one of two weekly, one-hour, school-based group interventions-Storytelling/Story-Acting for Adolescents (STSA-A) or Mentalization-Based Treatment Group Intervention (MBT-G). The Object Relations Inventory (ORI), Adolescent Attachment Questionnaire (AAQ) and Child PSTD Stress Scale (CPSS) were administered to students and their primary group leaders at the beginning (October) and end (May) of the intervention protocol as outcome variables. Participants in both the STSA-A and MBT-G intervention conditions experienced significant increases in attachment security and decreases in trauma symptoms. Over the course of eight months of group intervention, affective valence of paternal mental representations significantly decreased for boys and for participants in the STSA-A condition, while affective valence of primary group leader mental representations significantly decreased for participants in the MBT-G condition. STSA-A and MBT-G were found to be efficacious at improving attachment security and reducing trauma symptoms in young adolescents. The strengths of each group intervention for addressing interpersonal issues unique to specific types of adolescents are discussed.

Predictors of representational aggression in preschool children of low-income urban African American adolescent mothers.

Responses to five doll-story stems thematically related to attachment experiences with the mother were videotaped in the home and used to evaluate child, maternal, and environmental predictors of representational aggression in 93 preschool children of African American women receiving public assistance who had become pregnant as teenagers. Significant correlations were found between representational aggression and child's gender (male), birth weight, maternal depressive affect, maternal educational attainment, recent employment, mother's historical residence with her own mother, and felt social support, accounting for 40% of the variance in representational aggression. A significant Felt Social Support × Gender interaction effect suggested that girls of mothers who perceive higher levels of felt social support are more likely to represent less aggression in their stories; felt social support was not associated with boys' representational aggression. A significant Felt Social Support × Employment interaction effect suggested that representational aggression is associated with lower levels of felt social support only among employed mothers. Findings suggest that different pathways exist for representational aggression in children of low-income adolescent mothers, which nevertheless share predictors associated with poverty.

Reflective function and identity in adolescents with clinical and nonclinical symptoms.

INTRODUCTION: Reflective function is developed in the context of secure attachment and corresponds to the ability to understand one's mental states and those of others. Thus, identity develops, which relates to the experience of self as unique, continuous and coherent. OBJECTIVE: To identify reflective function and identity features in adolescents with clinical and nonclinical symptoms of mental health problems. METHOD: Participants were 188 Brazilian high school students aged 14-17 years: 30.3% with clinical symptoms and 69.9% with nonclinical symptoms. RESULTS: Adolescents with clinical symptoms showed lower levels of reflective function and greater disintegration of identity. CONCLUSION: Adolescence is a vulnerable time for mental health problems associated with reflective function and identity. Early identification of symptoms is a matter that needs attention to prevent future consequences.

ADHD and aggression as correlates of suicidal behavior in assaultive prepubertal psychiatric inpatients.

Forty-three psychiatrically hospitalized prepubertal children were assessed regarding their assaultive and suicidal behaviors. These children were subsequently classified into two groups, assaultive/suicidal (AS) and assaultive-only (AO). AS children had higher aggression and suicidal-scale scores, but not higher depression scores, and were more likely to be diagnosed with ADHD. ADHD, child's aggression, and maternal depression and state anger accounted for 33% of the variance in suicidal-scale scores. Aggression mediated the relation between ADHD and suicidal behavior. Differences in symptom pattern between these two subtypes of assaultive inpatient children are interpreted as a basis for distinctive screening procedures.

Representations of God uncovered in a spirituality group of borderline inpatients.

We present aspects of a psychoanalytically-oriented, exploratory spirituality group for nine female psychiatric inpatients diagnosed with borderline personality disorder. Through drawings and group process, the patients uncovered and elaborated on their representations of God. Two patterns of representations were identified: (1) representations of a punitive, judgmental, rigid God that seemed directly to reflect and correspond with parental representations and (2) representations of a depersonified, inanimate, abstract God entailing aspects of idealization that seemed to compensate for parental representations. Interestingly, the second pattern was associated with comorbid narcissistic features in the patients. Those patients who presented punitive God representations were able to begin the process of re-creating these representations toward more benign or benevolent images in the context of this group, while those participants who presented depersonified God representations seemed unable to do so.

Simulation modeling analysis of sequential relations among therapeutic alliance, symptoms, and adherence to child-centered play therapy between a child with autism spectrum disorder and two therapists.

This study examined the sequential relations among three pertinent variables in child psychotherapy: therapeutic alliance (TA) (including ruptures and repairs), autism symptoms, and adherence to child-centered play therapy (CCPT) process. A 2-year CCPT of a 6-year-old Caucasian boy diagnosed with autism spectrum disorder was conducted weekly with two doctoral-student therapists, working consecutively for 1 year each, in a university-based community mental-health clinic. Sessions were video-recorded and coded using the Child Psychotherapy Process Q-Set (CPQ), a measure of the TA, and an autism symptom measure. Sequential relations among these variables were examined using simulation modeling analysis (SMA). In Therapist 1's treatment, unexpectedly, autism symptoms decreased three sessions after a rupture occurred in the therapeutic dyad. In Therapist 2's treatment, adherence to CCPT process increased 2 weeks after a repair occurred in the therapeutic dyad. The TA decreased 1 week after autism symptoms increased. Finally, adherence to CCPT process decreased 1 week after autism symptoms increased. The authors concluded that (1) sequential relations differ by therapist even though the child remains constant, (2) therapeutic ruptures can have an unexpected effect on autism symptoms, and (3) changes in autism symptoms can precede as well as follow changes in process variables.

Therapists' perspectives on optimal treatment for pathological narcissism.

This study used Q methodology to explore clinicians' perspectives regarding optimal psychotherapy process in the treatment of pathological narcissism, a syndrome of impaired self-regulation. Participants were 34 psychotherapists of various disciplines and theoretical orientations who reviewed 3 clinical vignettes portraying hypothetical cases of grandiose narcissism, vulnerable narcissism, and panic disorder without pathological narcissism. Participants then used the Psychotherapy Process Q set, a 100-item Q-sort instrument, to indicate their views regarding optimal therapy process for each hypothetical case. By-person principal components analysis with varimax rotation was conducted on all 102 Q-sorts, revealing 4 components representing clinicians' perspectives on ideal therapy processes for narcissistic and non-narcissistic patients. These perspectives were then analyzed regarding their relationship to established therapy models. The first component represented an introspective, relationally oriented therapy process and was strongly correlated with established psychodynamic treatments. The second component, most frequently endorsed for the panic disorder vignette, consisted of a cognitive and alliance-building approach that correlated strongly with expert-rated cognitive-behavioral therapy. The third and fourth components involved therapy processes focused on the challenging interpersonal behaviors associated with narcissistic vulnerability and grandiosity, respectively. The perspectives on therapy processes that emerged in this study reflect different points of emphasis in the treatment of pathological narcissism, and may serve as prototypes of therapist-generated approaches to patients suffering from this issue. The findings suggest several areas for further empirical inquiry regarding psychotherapy with this population. (PsycINFO Database Record

Mother expectation of bother and infant attachment behaviors as predictors of mother and child communication at 24 months in children of methadone-maintained women.

This study used a transactional model of development (Sameroff, 1975) to test whether methadone exposure, mother's expectation of her future infant's degree of bother during pregnancy, infant attachment behaviors assessed at 12 months, and mother and child communication assessed at 24 months reciprocally influence each other in a sample of 30 full-term, African American toddlers exposed in utero to methadone and 42 comparison toddlers. Toddlers were videotaped at 24 months communicating with their mothers in eight scripted situations and at 12 months participating in a separation-reunion procedure to assess attachment behaviors. Mothers in both groups were comparable on race, education, age, SES, parity, IQ, and marital status. The relation between methadone exposure and the quality of mother communication was found to be moderated by mother's expectation of her future infant's degree of bother and mediated by avoidant attachment behavior. Infants' disorganized attachment behavior predicted their own lower quality communication at 24 months regardless of methadone exposure. The organization of affect regulation in both members of the dyad can differentially affect the ways in which methadone exposure impacts on the quality of mother communication by 24 months. Results suggest that preventive intervention is most likely to succeed when both mothers and children participate.

"I feel stupid and contagious:" countertransference reactions of fledgling clinicians to patients who have negative therapeutic reactions.

Patients who are prone to having negative therapeutic reactions seem to be increasingly common in clinical practice. These patients pose special problems for graduate students, psychoanalytic candidates, and other clinicians who struggle with anxiety regarding their new role and their feelings of incompetence and helplessness associated with the belief that their therapeutic efforts will result in treatment failure. The fledgling clinician thus provides fertile ground for this kind of patient to project her or his concerned, depressed, and guilty self-representation into the clinician. The fledgling clinician, owing to an incomplete integration in her or his own internal object world, is also capable of projecting dead or damaged and dying object-representations into this kind of patient, who sometimes responds by withdrawing from or leaving treatment. It is argued that although we must acknowledge the limitations of our therapeutic technique with this kind of patient, identification and interpretation of projective identification are essential to increase the likelihood of therapeutic success. Finally, rigorous education in severe psychopathology, exploration of one's intrapsychic conflicts, and participation in individual or peer clinical supervision, are recommended, as well as an interpretative emphasis on both the deeply buried love for the internal object world as well as its destruction.

Empirical evidence supporting the conceptual relatedness of object representations and internal working models.

The proliferation of new developmental and clinical theories broadly termed "psychoanalytic" demands a methodology for making systematic comparisons to establish the commonalities and distinctions among them. This article presents an empirical method for the comparative evaluation of such theories. The Mother-To-Child Object Representation / Internal Working Model Q-sort is a 100-item instrument constructed to assess the quality of the prototypical mother's object representation and internal working model of her child at age five. Object relations judges were asked to sort these items for a complex, differentiated, integrated object representation of a five-year-old, attachment judges for a secure, coherent, freely valuing internal working model of a five-year-old. Judges' criterion Q-sorts in each group yielded a composite criterion Q-sort of the quality of the prototypical mother's mental representation of her child according to each group's theoretical perspective. The Spearman-Brown correlation between the two composite criterion Q-sorts was r = .90, p < .001 , suggesting that when confined to a 100-item common vocabulary, judges representing each theoretical construct agreed on the conceptual relatedness of object representations and internal working models. The theoretical constructs of object representations and internal working models share common assumptions in need of further exploration.

Assessing levels of similarity to a "psychodynamic prototype" in psychodynamic psychotherapy with children: a case study approach (preliminary findings).

OBJECTIVE: To analyze the degree of similarity to a "psychodynamic prototype" during the first year of two children's once-weekly psychodynamic psychotherapy. METHODS: This study used a longitudinal, descriptive, repeated-measures design based on the systematic case study method. Two male school children (here referred to as Walter and Peter) and their therapists took part in the study. All sessions were video and audio recorded. Ten sessions from each case were selected for analysis in this preliminary study. Trained examiners (randomly selected in pairs) independently and blindly evaluated each session using the Child Psychotherapy Q-Set (CPQ). Experts in psychodynamic therapy and cognitive behavioral therapy from several countries rated each of the 100 CPQ items with regard to how well it characterized a hypothetical ideal session of either treatment modality. A series of paired t tests comparing analogous adherence scores within each session were conducted. RESULTS: There were no significant correlations between time elapsed and adherence to the prototypes. Walter's treatment adhered to both prototypes and Peter's treatment did not adhere to either prototype. CONCLUSION: Child psychotherapy theory and practice are not absolutely coincident. Real psychotherapy sessions do not necessarily resemble the ideal prototypes.

Interaction structures formed in the psychodynamic therapy of five patients with borderline personality disorder in crisis.

OBJECTIVES: To identify interaction structures (i.e., patterns of reciprocal interaction) that characterize the treatments of patients with borderline personality disorder (BPD) in crisis. DESIGN: A 6-month naturalistic psychotherapy process and outcome study in which interaction structures were correlated with outcome data. METHODS: Five BPD patients in crisis participated in 6 months of three-times-per-week psychodynamic therapy. Patients completed a measure of psychological distress every week. One hundred and twenty-seven sessions were audiotaped and coded using the Psychotherapy Process Q-Set. RESULTS: Four interaction structures were identified: (1) collaborative relationship with supportive, reassuring therapist (IS1), (2) therapist empathic attunement (IS2), (3) erotized therapeutic relationship (IS3) and (4) directive therapist with compliant patient (IS4). The magnitude of these four interaction structures varied within and between the five therapist-patient dyads over time. Interaction structures correlations with time were inversely proportional to interaction structures correlations with distress levels. IS2 was correlated with two different outcomes in patient 3's and patient 5's treatments--a positive outcome for patient 3's treatment and a negative outcome for patient 5's treatment. CONCLUSIONS: An effective treatment model for BPD patients in crisis needs to promote the emergence of empathically attuned interactions as well as supportive and directive interventions as dictated by the patient's individual needs. These treatments require flexibility to accommodate the patient's unique presentation in crisis. The therapeutic dyad senses which interaction structures to increase or decrease over time to reduce the patient's distress.

Reflective function and identity in adolescents with clinical and nonclinical symptoms / Função reflexiva e identidade em adolescentes com sintomas clínicos e não clínicos

Abstract Introduction Reflective function is developed in the context of secure attachment and corresponds to the ability to understand one's mental states and those of others. Thus, identity develops, which relates to the experience of self as unique, continuous and coherent. Objective To identify reflective function and identity features in adolescents with clinical and nonclinical symptoms of mental health problems. Method Participants were 188 Brazilian high school students aged 14-17 years: 30.3% with clinical symptoms and 69.9% with nonclinical symptoms. Results Adolescents with clinical symptoms showed lower levels of reflective function and greater disintegration of identity. Conclusion Adolescence is a vulnerable time for mental health problems associated with reflective function and identity. Early identification of symptoms is a matter that needs attention to prevent future consequences.

Resumo Introdução A função reflexiva é desenvolvida no contexto do apego seguro e corresponde à capacidade de compreender os seus próprios estados mentais e os dos outros. Assim, desenvolve-se a identidade, que se relaciona com a experiência do eu como única, contínua e coerente. Objetivo Identificar função reflexiva e características identitárias em adolescentes com sintomas clínicos e não clínicos de problemas de saúde mental. Médoto Os participantes foram 188 estudantes do ensino médio com idade de 14 a 17 anos: 30,3% com sintomas clínicos e 69,9% com sintomas não clínicos. Resultados Adolescentes com sintomas clínicos apresentaram menores níveis de função reflexiva e maior desintegração da identidade. Conclusão A adolescência é um momento vulnerável para problemas de saúde mental associados à função reflexiva e identidade. A identificação precoce dos sintomas é uma questão que precisa de atenção para evitar consequências futuras.

Do attachment representations predict depression and anxiety in psychiatrically hospitalized prepubertal children?

Thirty-six prepubertal inpatients were videotaped completing five stories thematically related to attachment experiences and classified by their attachment representations. Children also completed the Children's Depression Inventory and Diagnostic Interview for Children and Adolescents-Revised. Mothers completed demographic questionnaires. Percentage of secure (B) attachment was only about one tenth of the normative percentage, anxious-ambivalent (C) attachment was between two and three times the normative percentage, and disorganized (D) attachment was almost twice the normative percentage. Both D attachment and the total number of disorganized story responses were associated with negative self-esteem and clinical-range depression. Anxious-avoidant (A) attachment decreased the likelihood, while C and D attachment increased the likelihood, of separation anxiety disorder. Clinical intervention needs to focus on the meaning of parental relationships represented in the child's mind, specifically the negative self-esteem and separation anxiety associated with the lack of felt security provided by the parents.