Dynamic relations between mentalization techniques and therapeutic alliance in psychodynamic child therapy: An evidence-based case study.

Therapeutic alliance and mentalization are common factors inherent to all effective treatments. Mentalization-based interventions have the potential to create a safe relationship, which makes further mentalizing interventions possible. However, to date, no study has examined the bidirectional relationship between these variables in child psychotherapy. In an evidence-based case study design, psychodynamic therapy processes of two Turkish children (age: 9 and 10 years) who presented with social withdrawal problems were compared. All their sessions (34 sessions from Case No. 1 and 31 from Case No. 2) were coded using the Therapy Process Observational Coding System-Alliance Scale and Mentalization-Based Treatment for Children Adherence Scale. Outcome scales pertaining to symptoms, attachment, and mentalization were administered at baseline and at termination. Time-series Granger Causality tests revealed that in the case with clinically significant outcome, mentalization techniques predicted therapeutic alliance in the subsequent sessions, which predicted the use of further mentalization interventions. However, this relationship was not supported in the case with no significant improvement. Selected sessions were clinically analyzed with verbatim session vignettes. Our findings indicate that mentalization techniques in child therapy are closely related to the therapeutic relationship. (PsycInfo Database Record (c) 2023 APA, all rights reserved).

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.

Cross-Informant Compatibility of Depression Symptoms in Children: A Network Approach.

Utilizing multiple informants to assess children's depressive symptoms increases diagnostic accuracy, reliability, and validity of inferences. However, previous studies have found low to moderate agreement among informants. We applied network statistics to gain insight into children and their mothers' differential perceptions of depressive symptoms. The sample included children and mother dyads (n = 185) who applied to psychotherapy services at an outpatient university clinic. Mothers filled out the Child Behavior Checklist, which includes a depression subscale, and children filled out the Children's Depression Inventory. We computed association networks for thirteen depressive symptoms separately for children and mothers using the graphical LASSO. Sadness had the highest strength centrality in the networks of both children and mothers, but the pattern of connectivity and centrality of other symptoms differed. We discussed our findings within the framework of network theory.

Interaction Structures in Psychodynamic Psychotherapy for Adolescents.

Despite advances in psychotherapy research showing an evidence-base for psychodynamic psychotherapy (PDT) in adolescents, developmentally specific treatment characteristics are under-researched. We aimed to identify interaction structures (IS: reciprocal patterns of in-session interactions involving therapist interventions, patient behaviors, and the therapeutic relationship) and assess associations between IS and outcome. The study cohort comprised 43 adolescents (Mage = 13.02 years) with nonclinical, internalizing, and comorbid internalizing-externalizing problems in PDT. A total of 123 sessions from different treatment phases were rated based on the Adolescent Psychotherapy Q-Set (APQ). Outcome was assessed with the Brief Problem Monitor-Youth (BPM-Y) administered repeatedly over the treatment course. Principal component analysis of APQ items resulted in five IS, named "Negative Therapeutic Alliance", "Demanding Patient, Accommodating Therapist", "Emotionally Distant Resistant Patient", "Inexpressive Patient, Inviting Therapist", and "Exploratory Psychodynamic Technique" (EPT). Multilevel modeling analyses with Bayesian Markov chain Monte Carlo (MCMC) estimations indicated a two-way interaction effect between EPT and problem levels at baseline such that patients with lower problems at baseline showed good outcome in the context of EPT, whereas an inverse relationship was found for patients with higher problems. Findings provide empirical evidence for characteristic components of PDT for adolescents and preliminary answers about who benefits from psychodynamic techniques.

Psychodynamic technique and therapeutic alliance in prediction of outcome in psychodynamic child psychotherapy.

OBJECTIVE: This study is the first to investigate the effect of psychodynamic technique (PT), therapeutic alliance, and their interactions with outcome in psychodynamic child psychotherapy. METHOD: The sample comprised 79 Turkish children (mean age = 6.86 years, 38% girls) with discrete internalizing (22%), discrete externalizing (11%) and comorbid internalizing and externalizing (67%) problems. Independent raters coded 359 sessions from different phases of treatment using the Child Psychotherapy Process Q-Sort for PT and Therapy Process Observational Coding System-Alliance Scale. Problem-assessment measures were collected at intake and every 10th session in treatment using the Children's Behavior Checklist and Brief Problem Monitor. RESULTS: Multilevel modeling analyses indicated that the PT and therapeutic alliance interacted such that more use of the PT in the context of high therapeutic alliance predicted less problem behaviors, whereas in the context of low therapeutic alliance PT predicted more problem behaviors. This relationship was moderated by problem comorbidity such that for children with comorbid problems, though a strong therapeutic alliance was indicated, an increase in PT use did not have a significant effect. CONCLUSION: Findings suggest that the use of psychodynamic interventions is indicated in the context of a strong therapeutic alliance, especially for children with noncomorbid problems. Psychodynamic interventions may have an adverse effect if a therapeutic alliance is not established. For children with comorbid problems, keeping the relationship strong is important. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Parental reflective function and children's attachment-based mental state talk as predictors of outcome in psychodynamic child psychotherapy.

Mentalization, operationalized as reflective function, is defined as the capacity to understand behavior in terms of mental states. Mentalization can be self-focused (i.e., mentalizing that focuses on one's own thoughts and feelings) or other-focused (i.e., mentalizing that focuses on others' thoughts and feelings). Some studies in adult psychotherapy show the importance of patients' mentalization capacity for treatment outcome; however, this has not yet been investigated in psychodynamic child psychotherapy. This study aimed to investigate whether baseline parental reflective function (PRF) and children's mental state talk (MST) predicted changes in emotional and behavioral problems in psychodynamic child psychotherapy. The sample included 60 Turkish school-age children (Mage = 7.90, SD = 1.35, 43.3% girls) with internalizing (18.3%), externalizing (5%), and comorbid (56.7%) problems, and 20% of the children were in the nonclinical range. The mothers were interviewed using the Parent Development Interview, which was coded for PRF (self- and child-focused). Children were administered an attachment-based story stem task, coded for MST (self- and other-focused). The Brief Problem Monitor was administered every month over the course of treatment for a total of 366 sessions. Multilevel modeling analyses indicated that mothers' child-focused PRF and children's self-focused MST predicted changes in problem behaviors. Parents' mentalization about their children and children's mentalization about their own internal states could be predictors of treatment response in psychodynamic child psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Multimodal affect analysis of psychodynamic play therapy.

Objective: We explore state of the art machine learning based tools for automatic facial and linguistic affect analysis to allow easier, faster, and more precise quantification and annotation of children's verbal and non-verbal affective expressions in psychodynamic child psychotherapy. Method: The sample included 53 Turkish children: 41 with internalizing, externalizing and comorbid problems; 12 in the non-clinical range. We collected audio and video recordings of 148 sessions, which were manually transcribed. Independent raters coded children's expressions of pleasure, anger, sadness and anxiety using the Children's Play Therapy Instrument (CPTI). Automatic facial and linguistic affect analysis modalities were adapted, developed, and combined in a system that predicts affect. Statistical regression methods (linear and polynomial regression) and machine learning techniques (deep learning, support vector regression and extreme learning machine) were used for predicting CPTI affect dimensions. Results: Experimental results show significant associations between automated affect predictions and CPTI affect dimensions with small to medium effect sizes. Fusion of facial and linguistic features work best for pleasure predictions; however, for other affect predictions linguistic analyses outperform facial analyses. External validity analyses partially support anger and pleasure predictions. Discussion: The system enables retrieving affective expressions of children, but needs improvement for precision.

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.

Therapeutic alliance trajectories and associations with outcome in psychodynamic child psychotherapy.

OBJECTIVE: This study investigated therapeutic alliance (TA) trajectories, their demographic and symptomatic predictors, and associations with outcome in psychodynamic child psychotherapy. METHOD: The sample included 89 Turkish children (Mage = 6.87, SD = 2.11, 46% girls) with internalizing (37.11%), externalizing (21.14%), and comorbid (38.20%) problems; 12% of the children were in the nonclinical range. Independent raters coded 328 sessions from different phases of treatment using the Therapy Process Observational Coding System-Alliance Scale. Outcome measures were collected at intake and termination (Children's Behavior Checklist and Teacher Rating Form). RESULTS: Multilevel growth curve modeling indicated that TA showed a quadratic trend (high-low-high) over the course of treatment. The shape-of-change methodology indicated three subgroups following a stable pattern, a slow and an accelerated quadratic TA trajectory. Externalizing problems (teacher report) negatively predicted average TA strength. Boys and children with internalizing problems showed a declining TA trajectory, whereas children with externalizing problems (teacher report) showed an upward TA trajectory. Multivariate multiple regression analyses showed that the average TA (i.e., intercept) and the positive quadratic slope (the high-low-high pattern) positively predicted changes in internalizing and externalizing problems (teacher report). DISCUSSION: This study was the first to show the course of TA development in psychodynamic child psychotherapy, identify a number of child characteristics that facilitate and impede TA. Investigating both the strength and patterns of TA development when examining associations with outcome is important. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mentalization, session-to-session negative emotion expression, symbolic play, and affect regulation in psychodynamic child psychotherapy.

Internalizing and externalizing problems have been related to negative emotionality, and affect regulation deficits in several studies. Certain psychodynamic models of treatment use children's symbolic play activity as a medium to mentalize negative emotions in order to develop children's affect regulation. However, the complex associations among these constructs and their associations with outcome have not been examined. This study aimed to investigate, first, whether average mentalization practices in treatment, as well as session-to-session expression of negative emotions and symbolic play predict gains in affect regulation and, second, whether changes in these variables are associated with clinically significant change in symptoms and global function. The sample included 40 outpatient children, who underwent long-term psychodynamic treatment. Nine hundred seventy-five sessions were coded for children's symbolic play, affect expression (anger and dysphoric affect), and affect regulation characteristics, and each treatment was scored for average adherence to mentalizing principles. Time Series Panel Analyses (TSPA) indicated session-to session use of symbolic play predicted gains in affect regulation. A significant 2-way interaction indicated that dysphoric affect expression in high mentalization adherent treatments was associated with higher affect regulation than in low adherent treatments. Partial correlation analyses indicated that mentalization adherence in treatment was associated with symptomatic improvement at trend level of significance, and changes in affect regulation and symbolic play were significantly associated with gains in global function. Findings point to the importance of use of symbolic play, and dysphoric affect expression in the context of mentalization practices for gains in affect regulation and outcome. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Mentalization and the growth of symbolic play and affect regulation in psychodynamic therapy for children with behavioral problems.

Objective: Children with behavioral problems often have problems with symbolic play organization, specifically with the regulation of negative affect and its representation. One of the aims of psychodynamic therapy with these children is enhancing their symbolic and mentalizing capacities in play. This study investigated the associations between promoting mentalization, and the growth of symbolic play and affect regulation. Method: The sample included 48 children with behavioral problems, who underwent long-term psychodynamic treatment informed with mentalization principles, with good outcome. Three hundred twenty-nine sessions were coded for children's symbolic play and affect regulation strategies, and each treatment was rated for adherence to mentalizing principles. Results: Hierarchical linear modeling showed quadratic growth of variables, wherein symbolic play initially increased followed by a deceleration in change, whereas affect regulation initially decreased followed by an increase. Adherence to mentalizing principles was associated with both symbolic play and affect regulation. A two-way interaction between time in treatment and adherence to mentalization showed that in high adherent treatments, affect regulation increased towards the end of treatment, whereas in low adherent treatments, there was no change. Conclusion: Results show support for the association between adherence to mentalization and growth of affect regulation and symbolic play in psychodynamic therapy.

Transference interpretations as predictors of increased insight and affect expression in a single case of long-term psychoanalysis.

Improved insight and affect expression have been associated with specific effects of transference work in psychodynamic psychotherapy. However, the micro-associations between these variables as they occur within the sessions have not been studied. The present study investigated whether the analyst's transference interpretations predicted changes in a patient's insight and emotion expression in her language during the course of a long-term psychoanalysis. 449 thematic units from 30 sessions coming from different years of psychoanalysis were coded by outside raters for analyst's use of transference interpretations using Transference Work Scale, and patient's insight, positive emotions, anger and sadness were calculated using the Linguistic Inquiry and Word Count System. Multilevel modeling analyses indicated that transference interpretations positively predicted patient's insight and positive emotion words and negatively predicted anger and sadness. The qualitative micro-analyses of selected sessions showed that the opportunity to explore negative emotions within the transference relationship reduced the patient's avoidance of such feelings, generated insight into negative relational patterns, and helped form more balanced representations of self and others that allowed for positive feelings. The findings were discussed for clinical implications and future research directions.

Monitoring Nonlinear Dynamics of Change in a Single Case of Psychodynamic Play Therapy.

A systematic single case study with a mixed quantitative and qualitative methodology was conducted to investigate the nonlinear dynamics of change in play profiles of a child in psychodynamic play therapy. The first aim of the study was to cluster the different features of play characteristics (i.e., descriptive, cognitive, affective, and social characteristics of play, and the defensive strategies used in play) in order to construct the different play profiles of this child, and secondly to assess the transitions between profiles over the course of treatment. It was expected that there would be an increase in critical fluctuations during the transitions between the profiles and an increase in the variability of play profiles. Results showed that the child's play characteristics clustered into eight states and three attractors. The Markov Transition Matrix showed how play profiles evolved over time. Entropy analyses comparing the first and the second half of therapy showed an increase in variability. Qualitative analyses indicated the importance of expression of the child's underlying fear, and its integration with overt anger in the generation of the new play profiles. The results indicate an increase in variability, and a destabilization of old play profiles that were used towards generating new play profiles.

An empirical analysis of mental state talk and affect regulation in two single-cases of psychodynamic child therapy.

Literature has shown the importance of mentalizing techniques in symptom remission and emotional understanding; however, no study to date has looked at the dynamic relations between mental state talk and affect regulation in the psychotherapy process. From a psychodynamic perspective, the emergence of the child's capacity to regulate affect through the therapist's reflection on the child's mental states is a core aspect of treatment. In an empirical investigation of 2 single cases with separation anxiety disorder, who were treated in long-term psychodynamic play therapy informed with mentalization principles, the effect of therapists' and children's use of mental state talk on children's subsequent capacity to regulate affect in play was assessed. One case was a positive outcome case, whereas the other did not show symptomatic improvement at the end of treatment. Children's and therapists' utterances in the sessions were coded using the Coding System for Mental State Talk in Narratives, and children's play was coded by Children's Play Therapy Instrument, which generated an index of children's "affect regulation." Time-series Granger Causality tests showed that even though both therapists' use of mental state talk significantly predicted children's subsequent affect regulation, the association between child's mental state talk and affect regulation was only supported for the child who showed clinically significant symptom reduction. This study provided preliminary support that mental state talk in psychodynamic psychotherapy facilitates emotion regulation in play. (PsycINFO Database Record

The Non-linear Trajectory of Change in Play Profiles of Three Children in Psychodynamic Play Therapy.

Aim: Even though there is substantial evidence that play based therapies produce significant change, the specific play processes in treatment remain unexamined. For that purpose, processes of change in long-term psychodynamic play therapy are assessed through a repeated systematic assessment of three children's "play profiles," which reflect patterns of organization among play variables that contribute to play activity in therapy, indicative of the children's coping strategies, and an expression of their internal world. The main aims of the study are to investigate the kinds of play profiles expressed in treatment, and to test whether there is emergence of new and more adaptive play profiles using dynamic systems theory as a methodological framework. Methods and Procedures: Each session from the long-term psychodynamic treatment (mean number of sessions = 55) of three 6-year-old good outcome cases presenting with Separation Anxiety were recorded, transcribed and coded using items from the Children's Play Therapy Instrument (CPTI), created to assess the play activity of children in psychotherapy, generating discrete and measurable units of play activity arranged along a continuum of four play profiles: "Adaptive," "Inhibited," "Impulsive," and "Disorganized." The play profiles were clustered through K-means Algorithm, generating seven discrete states characterizing the course of treatment and the transitions between these states were analyzed by Markov Transition Matrix, Recurrence Quantification Analysis (RQA) and odds ratios comparing the first and second halves of psychotherapy. Results: The Markov Transitions between the states scaled almost perfectly and also showed the ergodicity of the system, meaning that the child can reach any state or shift to another one in play. The RQA and odds ratios showed two trends of change, first concerning the decrease in the use of "less adaptive" strategies, second regarding the reduction of play interruptions. Conclusion: The results support that these children express different psychic states in play, which can be captured through the lens of play profiles, and begin to modify less dysfunctional profiles over the course of treatment. The methodology employed showed the productivity of treating psychodynamic play therapy as a complex system, taking advantage of non-linear methods to study psychotherapeutic play activity.