Measuring mentalizing in youth: further validation of the reflective functioning questionnaire for youth (RFQY-13).

Objective: This study investigated the psychometric properties, including the factor structure, validity, and reliability of the 13-item Reflective Function Questionnaire for Youth (RFQY-13), using a new scoring system. Method: A community sample of 414 adolescents and a clinical sample of 83 adolescents (aged 12-21) completed the RFQY, the Borderline Personality Features Scale for Children (BPFS-C), the Beck Youth Inventories (BYI), the Child Behavior Checklist-Youth Self Report (CBCL-YSR) and the Movie for the Assessment of Social Cognition (MASC). Results: Using the new scoring system, our results demonstrated configural and metric invariance, as well as adequate reliability and validity across both samples for the two-factor structure of the RFQY. The Uncertainty subscale also showed strong associations with psychopathology. Discussion: The findings show that the RFQY-13, when used with the new coding system, has good psychometric properties and is a reliable measure of mentalizing for adolescents and young adults. We discuss clinical implications, limitations and future directions.

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

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

Videoconferencing psychotherapy from a psychodynamic point of view. A qualitative analysis.

There is a growing interest in delivering videoconferencing psychotherapy (VCP) due to the enormous impact of the COVID-19 pandemic on our lives since the beginning of severe restrictions worldwide in March 2020. Scientific literature has provided interesting results about the transition to remote sessions and its implications, considering different psychotherapy orientations. Less is known about whether and how VCP affects psychodynamic psychotherapeutic approaches and reports on remote work with severe and complex mental health problems such as severe personality disorders are still scarce. The aim of the study was to examine the experiences of psychodynamic psychotherapists, mainly delivering Transference-Focused Psychotherapy (TFP), with the transition and delivery of VCP during the first wave of the COVID-19 pandemic. Four hundred seventy-nine licensed psychotherapists completed an online survey during the peak of the pandemic. Survey data were analyzed using qualitative analysis. Results are presented and discussed concerning advantages and disadvantages regarding the access to psychotherapy, the specificity of the online video setting, bodily aspects, the quality of the therapeutic relationship, the therapeutic process including technical aspects and therapist's experience. Furthermore, we analyzed and discussed the statements concerning transference and countertransference reactions differentiating between high-level borderline and neurotic patients and low-level borderline patients. Our results support the importance to identify patients who potentially benefit from VCP. Further research including more prospective randomized controlled trials are needed to investigate the therapeutic implications of the findings.

Adolescent mentalizing and childhood emotional abuse: implications for depression, anxiety, and borderline personality disorder features.

Background: There is preliminary evidence that childhood emotional abuse (CEA) is a risk factor for adolescent mentalizing difficulties (Uncertainty/Confusion about mental states) and borderline personality features and that Uncertainty/Confusion about mental states mediate the relationship between CEA and adolescent borderline personality features, but these findings need replication. Furthermore, no previous studies have examined the relationship between adolescent mentalizing deficits, anxiety, and depression in the context of CEA. Objectives: This study examined the associations between CEA, adolescent borderline personality features, depression and anxiety symptoms and tested a pathway model where Uncertainty/Confusion about mental states mediates the relationships between CEA and adolescent borderline personality features, depression and anxiety symptoms. Method: A clinical sample of 94 adolescents completed the Reflective Function Questionnaire for Youth (RFQY) to assess mentalizing, the Childhood Experiences of Care and Abuse Questionnaire (CECA-Q), the Borderline Personality Disorders Features Scale (BPFS-C), and the Beck Youth Inventories for Depression (BDI-Y) and Anxiety (BAI-Y). Results: Uncertainty/Confusion about mental states partially mediated the relationship between CEA and borderline traits as well as anxiety. In addition, there was an indirect effect where CEA predicted Uncertainty/Confusion about mental states, which then predicted depression. Discussion: The findings are consistent with the mentalizing model of psychopathology and provide new evidence that Uncertainty/Confusion about mental states might be a critical mentalizing deficit that characterizes the associations between CEA and adolescent BPD features and depression and anxiety symptoms. Uncertainty/Confusion may be a transdiagnostic risk factor for adolescent psychological distress and dysfunction. We discuss the clinical implications.

Post-traumatic-stress in the context of childhood maltreatment: pathways from attachment through mentalizing during the transition to parenthood.

Introduction: This study aimed to clarify the role of mentalizing in pathways from attachment to Post Traumatic Stress Symptoms (PTSS) in survivors of childhood maltreatment (CM). We focused on the transition to parenting, a critical period for reworking parenting representations to reduce intergenerational maltreatment cycles. Method: Study participants included 100 pregnant CM survivors. We assessed PTSS with the SCID and attachment and mentalizing with the Adult Attachment Interview (AAI), which was rated for Attachment and Reflective Functioning (RF). Results: Regarding Re-experiencing trauma symptoms, the results of the path analysis were consistent with mediation. CM survivors' mentalizing about their early relationships with their parents (RF-Other) directly impacted Re-experiencing trauma symptoms, and attachment had an effect on Re-experiencing trauma symptoms through mentalizing (RF-Other). Regarding Arousal/Reactivity symptoms, the results of the pathways analysis were consistent with partial mediation by mentalizing about early relationships with parents (RF-Other). In addition to the pathway from attachment via mentalizing (RF-Other) to Arousal/Reactivity, the pathway between attachment and Arousal/Reactivity also remained significant. Discussion: This study provides new evidence of a mentalizing and attachment model of PTSS in CM survivors. The findings indicate that increased mentalizing about early relationships with parents is an important process associated with lower PTSS. Finally, we discuss the implications of developing interventions for CM survivors to reduce PTSS. Scaffolding the development of mentalizing regarding attachment relationships in which CM occurred may help CM survivors reduce the intrusion of traumatic memories and decrease trauma-related arousal and reactivity symptoms. Interventions to help CM survivors mentalize regarding parents and attachment relationships in which trauma occurred may be particularly important during the transition to parenting when activation of representations of parenting can trigger PTSS.

An Integrated Developmental Approach to Personality Disorders in Adolescence: Expanding Kernberg's Object Relations Theory.

This article is a tribute to Dr. Otto F. Kernberg and his contribution to the theoretical understanding of personality pathology in adolescence. In his object relations theory of the structure of personality, an integrated identity is considered central to healthy personality functioning and is contrasted with identity diffusion, which is posited to underlie the maladaptive interpersonal functioning of patients with severe personality disorders. His work provided an early theoretical foundation for the understanding and treatment of personality disorders in adults, but a need remained for a deeper understanding of the development and treatment of personality disorders during adolescence. During the past 10 years, Kernberg has led a group of clinicians and developmental researchers focusing on childhood and adolescence to elaborate an understanding of the development, assessment, and treatment of personality disorders among adolescents. He proposed that in the context of typical development, adolescence is important to the expansion of identity, because it represents the period when sexual and aggressive impulses are integrated and earlier representations of the self and others are revised and become more realistic and nuanced. Furthermore, adolescence entails a reorganization of the moral system and enrichment of the ego ideal. This article presents two methods for assessing personality disorders in adolescence that are based on Kernberg's theory and demonstrates the use of transference-focused psychotherapy for adolescents with personality disorders.

Dimensional model of adolescent personality pathology, reflective functioning, and emotional maltreatment.

Introduction: Childhood emotional abuse (CEA) is a recognized risk factor for adolescent mentalizing challenges. However, there's limited understanding about how CEA might influence personality development and elevate the risk of adolescent personality pathology. A deeper grasp of these pathways is crucial, given that adolescence is a pivotal developmental phase for identity integration, personality consolidation, and the emergence of personality disorders. As the emphasis shifts to dimensional perspectives on adolescent personality pathology, the spotlight is increasingly on adolescents' evolving personality organization (PO). Within this framework, personality disorder manifestations stem from inherent vulnerabilities in PO. A comprehensive understanding of how CEA leads to these inherent vulnerabilities in PO can inform enhanced interventions for at-risk adolescents. Nonetheless, our comprehension lacks insight into potential pathways to PO, especially those involving external factors like maltreatment and individual traits like mentalizing. This study sought to bridge these gaps by employing latent factor analysis and structural equation modeling to explore connections between emotional maltreatment, adolescent mentalizing, and PO. Methods: A community-based cohort of 193 adolescents (aged 12-17) took part in self-report assessments: the Childhood Experience of Care and Abuse Questionnaire (CECA.Q), the Reflective Functioning Questionnaire for Youth (RFQ-Y), and the Inventory for Personality Organization for Adolescents (IPO-A). Results: The structural equation model revealed a significant direct influence of CEA on both RFQ-Confusion and PO, and a noteworthy direct effect of RFQ-Confusion on PO. Remarkably, the model accounted for 76.9% of the PO variance. CEA exhibited a significant indirect impact on PO through RFQ-Confusion, which was accountable for 52.3% of the CEA effect on PO, signifying a partial mediation by mentalizing. Discussion: These insights carry substantial clinical implications, especially for devising integrated, trauma-informed strategies for adolescents with personality pathologies. This is particularly relevant for enhancing mentalizing and bolstering personality consolidation among adolescent CEA survivors.

Post-traumatic Stress Disorder in Sexually Abused Children: Secure Attachment as a Protective Factor.

The aim of the present study was to examine the hypothesis that attachment and childhood sexual abuse (CSA) interacted such that school aged CSA survivors with insecure attachment to parents would be at an elevated risk of developing post-traumatic stress disorder (PTSD) and trauma symptoms. Participants (n = 111, ages 7-12) comprised two groups, child CSA survivors (n = 43) and a matched comparison group of children (n = 68) recruited from the community. Children completed the Child Attachment Interview (CAI) as well as the Trauma Symptom Checklist for Children (TSCC). There was a significant interaction between sexual abuse history and attachment security, such that sexually abused children with insecure attachment representations had significantly more PTSD and trauma symptoms than sexually abused children with secure attachment to parents. The findings show that using a dual lens of attachment and CSA can facilitate the identification of children most at risk and has important implications for understanding risk and resilience processes.

Transference-Focused Psychotherapy for Adolescents With Personality Disorders.

This article presents a conceptualization of personality disorders in adolescence and the adaptation of transference-focused psychotherapy (TFP) for personality disordered adolescents (TFP-A). The model of assessment and treatment presented is based on contemporary psychoanalytic object relations theory developed by Otto F. Kernberg and supported by findings from current evidence-based outcome research. We present a method of assessing personality disorders in adolescents that addresses the variability of personality disorder symptoms and traits among adolescents and their instability over time. We then present the goal of TFP-A and its major phases of implementation. A major focus is therapist interventions.

Risky Sexual Behavior Profiles in Youth: Associations With Borderline Personality Features.

Adolescence and young adulthood are peak periods for risky sexual behaviors (RSB) and borderline personality disorder (BPD) features. RSB is a major public health concern and adolescents with BPD may be particularly vulnerable to RSB, but this is understudied. The aim of this study was to identify distinct RSB profiles in youth and determine whether a specific profile was associated with BPD features. Participants were 220 adolescents and young adults (age 14-21) recruited from the community. To identify groups of adolescents and young adults who engage in similar RSB, a latent profile analysis (LPA) was conducted on sexually active youth (57%). Next ANOVA was used to identify how profiles differed in terms RSB dimensions and BPD features. We identified three distinct RSB profiles: (1) a Low RSB profile that was manifested by the majority (77.7%) of youth; (2) an Unprotected Sex in Relationships profile (13.3%) and; (3) an Impulsive Sex Outside Relationships profile (12%) which was manifested by youth with significantly higher BPD features. The findings shed light on the difficulties youth with BPD manifest around integrating sexuality, intimacy, fidelity, and love. This contrasts with the majority of youth who are sexually active in the context of relationships and engage in little or no RSB. The findings have important clinical implications. Adolescent sexuality is frequently in the blind spot of clinicians. To address the elevated risk of RSB in adolescents with BPD, interventions are needed to help adolescents navigate this period and improve their understanding of the reasons for RSB while addressing difficulties in establishing sexual and attachment relationships.

Childhood sexual abuse and attachment insecurity: Associations with child psychological difficulties.

Childhood sexual abuse (CSA) is considered an important public health concern that can derail the developmental course of children. Given that children rely upon their attachment figures when they experience upsetting events, attachment organization may play a critical role in predicting victims' adaptation to CSA. To date, no studies have delineated the unique and interactive contributions of these two risk factors in the prediction of psychopathology. The aims of this study were to examine attachment in CSA victims and a comparison group and to assess the contributions of each risk factor to child psychological difficulties. Participants included 111 children aged 7-13, of whom 43 were CSA victims. Children completed an attachment interview and reported on their depressive symptoms. Their mothers reported on children's externalizing symptoms, internalizing symptoms, dissociation, and sexualized behavior. Our key findings showed that child victims of CSA were more likely to be classified as having insecure and disorganized attachment. Further, insecure attachment was the primary factor associated with higher self-reported depressive symptoms in all children and that CSA was associated with more parent-reported child externalizing problems, sexualizing problems, and dissociation. (PsycINFO Database Record (c) 2020 APA, all rights reserved).

Maternal and Child Sexual Abuse History: An Intergenerational Exploration of Children's Adjustment and Maternal Trauma-Reflective Functioning.

Objective: The aim of the current study was to investigate associations, unique and interactive, between mothers' and children's histories of childhood sexual abuse (CSA) and children's psychiatric outcomes using an intergenerational perspective. Further, we were particularly interested in examining whether maternal reflective functioning about their own trauma (T-RF) was associated with a lower likelihood of children's abuse exposure (among children of CSA-exposed mothers). Methods: One hundred and eleven children (M age = 9.53 years; 43 sexual abuse victims) and their mothers (M age = 37.99; 63 sexual abuse victims) participated in this study. Mothers completed the Parent Development Interview (PDI), which yielded assessments of RF regarding their own experiences of abuse, and also reported on their children's internalizing and externalizing symptoms. Results: Children of CSA-exposed mothers were more likely to have experienced CSA. A key result was that among CSA-exposed mothers, higher maternal T-RF regarding their own abuse was associated with lower likelihood of child CSA-exposure. Mothers' and children's CSA histories predicted children's internalizing and externalizing symptoms, such that CSA exposure for mother or child was associated with greater symptomatology in children. Conclusion: The findings show that the presence of either maternal or child CSA is associated with more child psychological difficulties. Importantly in terms of identifying potential protective factors, maternal T-RF is associated with lower likelihood of CSA exposure in children of CSA-exposed mothers. We discuss these findings in the context of the need for treatments focusing on increasing T-RF in mothers and children in the context of abuse to facilitate adaptation and reduce the intergenerational risk.

Costs of Not Getting to Know You: Lower Levels of Parental Reflective Functioning Confer Risk for Maternal Insensitivity and Insecure Infant Attachment.

Parental reflective functioning (PRF) is a robust predictor of parenting sensitivity and secure infant attachment, but its assessment requires extensive resources, limiting its integration into research and clinical practice. The Mini-Parent Reflective Functioning Interview (Mini-PRFI) assesses the parent's capacity to mentalize for his/her 6-month-old infant (rated using the PRF coding system; Slade et al., 2004, PRF coding system and Slade REF, Unpublished protocol, New York, NY: The City University of New York). In the current study, we examined whether Mini-PRFI scores were associated with theoretically related constructs; to establish a point of comparison, we evaluated links between Mini-PRFI scores alongside RF assessed from the Adult Attachment Interview (AAI). Mother-infant dyads (N = 88) completed the AAI before the birth of the infant, the Mini-PRFI and an interaction task (rated for insensitive parental behavior) when infants were 6 months old, as well as the Strange Situation Procedure when infants were 16 months old. Mini-PRFI scores were strongly positively associated with AAI RF and negatively associated with maternal insensitivity. Mini-PRFI scores predicted infant attachment organization (secure/insecure, organized/disorganized) at 16 months, and this effect was mediated by parenting insensitivity. These findings suggest that the Mini-PRFI predicts theoretically related attachment constructs, demonstrating the promise of the Mini-PRFI to increase the accessibility of interview-based PRF measurements to clinicians and researchers.

Psychotherapy for Borderline Personality Disorder in Adolescents.

Research on borderline personality disorder (BPD) in adolescence has helped to clarify the characteristics of BPD in young people. The considerable emotional and economic cost associated with adolescent BPD supports calls for early intervention and requires that the assessment of personality functioning be an essential component in the psychological evaluation of adolescents. Adult treatment models with demonstrated efficacy have been adapted for adolescents. This article describes the implementation of these treatment approaches, factors that frequently complicate the recognition and diagnosis of BPD in young people, and an overview of research on BPD in adolescents that delineates its clinically relevant features.

Empirical typology of adolescent personality organization.

The concept of personality organization (PO) is central to current psychodynamic understanding of normal personality development as well as the development of personality disorders (PDs). However, individual differences in PO have primarily been studied in adult populations, and it remains unclear whether the clinical indicators of normal, neurotic and borderline PO manifest differently during adolescence. This study aimed to address the gaps in current knowledge regarding the potentially different manifestation of pathological PO in adolescence. In addition, we wanted to further establish the validity of the adolescent version of the Inventory of Personality Organization, by identifying cut-off points for each of the main dimensions of Normal, Neurotic, and Borderline PO. Participants included 430 adolescents (M = 16 years old) from the community. Cluster analysis identified three levels of PO corresponding to Normal, Neurotic, and Borderline PO. Cut- off points between the different POs were successfully established using ROC curve analyses.

Parental reflective functioning as a moderator of child internalizing difficulties in the context of child sexual abuse.

The objective was to examine pathways from child sexual abuse (CSA) and maternal mentalizing to child internalizing and externalizing difficulties and to test a model of MRF as a moderator of the relationships between CSA and child difficulties. The sample was comprised of 154 mothers and children aged 2-12 where 64 children had experienced CSA. To assess parental mentalizing the Parental Development Interview was rated with the Parental Reflective Functioning Scale. Child internalizing and externalizing difficulties were assessed with the Child Behavior Checklist (CBCL). Results indicate that there were significant inverse relationships between maternal mentalizing and child internalizing and externalizing difficulties. When maternal mentalizing was considered together with CSA, only maternal mentalizing was a significant predictor of child difficulties. Furthermore, maternal mentalizing moderated the relationship between CSA and child internalizing difficulties. These findings provide evidence of the importance of the parents' mentalizing stance for psychiatric symptoms of children aged 2-12, as well as children's recovery from CSA. The clinical implications of the findings are discussed.

REFLECTIVE FUNCTIONING AND PERSONALITY ORGANIZATION: ASSOCIATIONS WITH NEGATIVE MATERNAL BEHAVIORS.

The aim of this study was to examine whether mothers who manifest insensitive and disconnected behaviors in interaction with their infants differ in terms of maternal reflective functioning (RF), personality organization, and histories of abuse. A total of 86 mother-infant dyads, 28 of them with histories of abuse, participated in the study. RF was assessed with the Adult Attachment Interview (C. George, N. Kaplan, & M. Main, 1985), and personality organization was assessed with the self-report Inventory of Personality Organization (M.F. Lenzenweger, J.F. Clarkin, O.F. Kernberg, & P.A. Foelsh, 2001; L. Normandin et al., 2002), before the birth of the baby. Maternal behaviors were assessed using the Disconnected and Extremely Insensitive Parenting measure when the infants were 15 to 18 months old. The results of multivariate analyses of covariance indicate that both RF and personality organization were associated with disconnected and extremely insensitive maternal behaviors. Mothers classified as presenting intrusive/aggressive behaviors had significantly lower RF as well as significantly more difficulties in personality organization, including reality testing, identity, and defense mechanisms. Withdrawn and disconnected maternal behaviors were associated with the combination of difficulties in mentalization and personality organization rather than difficulties in one specific area. In sum, the study provides new evidence regarding the importance of a mentalizing stance about early attachment relationships for the modulation of maternal behaviors, especially intrusive/aggressive behaviors.

Dissociation mediates the relationship between sexual abuse and child psychological difficulties.

The aim of the present study was to evaluate, using structural equation modeling, a theoretical model in which dissociation is a core process mediating the relationship between childhood sexual abuse (CSA) and internalizing, externalizing, and sexualized behaviour difficulties in children. A total of 290 children aged 2-12 participated in this study in Québec, Canada from 1998 to 2004, including 138 children with histories of CSA and 152 non-abused children. To assess child dissociative symptoms, internalizing and externalizing difficulties, as well as sexualized behaviour difficulties, the Child Dissociative Checklist, the Child Behaviour Checklist and the Child Sexualized Behaviour Inventory were completed by parents. Dissociation mediated the relationship between CSA and internalizing, externalizing, and sexualized behaviour difficulties, with the model explaining respectively 42.5%, 49.9% and 33.9% of the variance of these difficulties. Findings are consistent with a model where dissociation is a common pathway linking CSA and child psycho-sexual difficulties.

Assessing Reflective Parenting in Interaction With School-Aged Children.

The aim of this study was to examine whether it was possible to develop a reliable and valid assessment of reflective parenting implicit in interaction with school-aged children using an adaptation of the Squiggle paradigm developed by Winnicott ( 1968 ) and a manualized coding system (Normandin, Leroux, Ensink, Terradas, & Fonagy, 2015 ). A total of 158 mother-child dyads participated when children were age 5 to 12. Of this group, 89 children had experienced sexual abuse. Interrater reliability using the manualized coding system was excellent. The factor analysis identified a reflective parenting stance factor, in addition to an affectionate support factor and a negative parenting factor. Furthermore, there was a medium strength relationship between the mother's reflective parenting stance evident in her interactions with her child and parental reflective functioning assessed using the Parent Development Interview (Slade, Aber, Bresgi, Berger, & Kaplan, 2004 ), suggesting the parental reflective stance is a good indicator of parental reflective functioning in interaction. With regard to parent reports of child internalizing and externalizing behaviors, the reflective parenting stance was the only predictor of internalizing difficulties and a significant predictor of externalizing difficulties in addition to sexual abuse.

Mentalization and dissociation in the context of trauma: Implications for child psychopathology.

Dissociation is a common reaction subsequent to childhood sexual abuse (CSA) and has been identified as a risk factor for child psychopathology. There is also evidence that mentalization contributes to resilience in the context of abuse. However, at this stage little is known regarding the relationship between mentalization and dissociation, and their respective contributions to psychopathology. The aim of this study was to examine pathways from CSA to depressive symptoms, externalizing behaviour difficulties and sexualized behaviour through mentalization and dissociation. These pathways were examined in a sample of 168 mother-child dyads, including 74 dyads where children (aged 7-12) had histories of sexual abuse. Maternal mentalization was assessed using the Parent Development Interview-Revised and children's mentalization was assessed using the Child Reflective Functioning Scale. Children completed the Child Depression Inventory and parents completed the Child Dissociative Checklist, the Child Behavior Checklist and the Child Sexual Behavior Inventory. Direct and indirect paths from CSA to child psychopathology via children's mentalization and dissociation were examined using Mplus. Distinct paths from abuse to psychopathology were identified. Child mentalization partially mediated the relationship between CSA and depressive symptoms. The effects of CSA on externalizing symptoms and sexualized behaviour difficulties were sequentially mediated through mentalization and dissociation.