The Relation between Mind‐mindedness in Mothers with Borderline Personality Disorder and Mental State Understanding in their Children

This study investigated relations between mind‐mindedness in mothers with borderline personality disorder (BPD) and mental state understanding in their children. Participants were 20 mothers with BPD and 19 mothers without personality disorder and their children, aged 39–61 months. Children's mental state understanding was examined via a battery of theory of mind and emotion labelling tasks. Maternal mind‐mindedness was assessed by mothers' use of mental state references to describe their children relative to other attributes. Maternal BPD was associated with fewer references to children's mental states as well as poorer levels of mental state understanding in their children. Findings lend some empirical support to recent theoretical suggestions that BPD is associated with a reduced capacity for mentalization, as well as reduced capacity for mental state understanding in children of mothers with BPD. Copyright © 2012 John Wiley & Sons, Ltd.     

Mentalization-based therapy with maltreated children living in shelters in southern Brazil: A single case study

This study describes the mentalization-based child therapy of a boy who suffered from early abuse and neglect, who was living in a shelter in southern Brazil. This single case study aimed at assessing whether this kind of psychotherapy contributes to reducing depressive symptoms and developing a greater capacity for reflection on the mental states of self and other, as part of developing a more coherent sense of self. Structured assessments were conducted before therapy and after six months of treatment, and the audio-recorded treatment sessions were analyzed using content analysis, in order to identify key themes in the treatment itself. The results suggested a significant improvement in depressive symptoms and some changes in mentalization with the beginnings of a movement toward a more cohesive and integrated self. We argue that mentalization-based child therapy could be a promising therapeutic approach for children who have experienced severe disruptions of emotional bonds, due to the way it focuses on the capacity to regulate affect and develop a more coherent sense of self.     

Dyadic Mental State Talk and Sophistication of Symbolic Play between Parents and Children with Behavioral Problems

Parents’ ability to recognize children’s mental states and use mental state language in their interactions are associated with children’s mentalization, affect regulation, and symbolization in play. However, the relations among these constructs have not been investigated in school-age children with behavioral problems. This study examined the association between 53 Turkish mother-child and 40 father-child dyads’ mental state talk, children’s play characteristics, and behavioral problems at the beginning of psychotherapy. Results indicated that parents’ and children’s play-related mental state talk was associated with children’s interactive role-play, and mothers’ mental state talk was associated with children’s affect regulation in play. Moreover, mental state talk through pretend play was linked with fewer internalizing symptoms; yet a direct focus on children’s mental states out-of-pretend play was correlated with more behavioral problems, highlighting the multidimensional nature of the mentalization construct. These results are discussed taking into account the socio-cultural variations of the Turkish culture highlighting the unique characteristics of the parent-child play in context. The clinical implications point to the importance of parental and child mentalization within pretend play, that provide opportunities for affect processing, which could promote symptomatic improvement.     

Konzept der Mentalisierung

Mentalization is the fundamental human capacity to relate to each other as minded beings. We mentalize when we are aware of mental states in others or ourselves as persons with feelings, wishes and beliefs. That is what makes the behavior of other people meaningful to us. Fonagy and colleagues based their mentalization concept on the attachment theory and on hypotheses about the development of the self. Mentalization-based treatment relies on this concept and has been manualized and evaluated for the treatment of borderline personality disorders. Psychotherapy research supports this to some extent. The authors claim that all psychotherapeutic treatment will benefit from the understanding of mentalization and its practical applications (Allen et al. 2008). Although the concept of mentalization is not new, the integration of different theories with empirically informed knowledge into a coherent concept is new.     

Treating Insecure Attachment in Group Therapy: Attachment Theory Meets Modern Psychoanalytic Technique

Attachment theory is a comprehensive, empirically supported theory of emotional, relational, and neurophysiological development. Modern psychoanalysis is a theory of technique that addresses early psychological deficits and conflicts considered beyond the reach of traditional psychoanalysis. Both orientations have influenced the theory and practice of group psychotherapy and emphasize personality maturation as a treatment goal. This paper explores their potential synergies when treating preoedipal, insecurely attached emotional states, disrupted emotional self-regulation, and impaired mentalization. Theoretical and technical applications are suggested that may enhance the treatment of disordered attachment in group psychotherapy. By addressing insecure attachment as resistance, modern psychoanalytic techniques may engage the emotional substrates of the attachment process to facilitate the expansion of relational capacities, mentalization, self-regulation, the differentiation of self/other representations, and epistemic trust.     

Transference Focused Psychotherapy for Patients with Comorbid Narcissistic and Borderline Personality Disorder

Clinical experience involving the treatment of patients with comorbid borderline and narcissistic personality disorders suggests that this patient population is among the more difficult to treat within the personality disorder spectrum. In this article, we present refinements of Transference Focused Psychotherapy (TFP) based on our clinical experience with and research data on patients with comorbid narcissistic personality disorder/borderline personality disorder (NPD/BPD). We briefly review object relations formulations of severe narcissistic pathology, as well as recent research in attachment and the allied concept of mentalization, which have provided a new lens through which to view narcissistic disorders. The research findings from two randomized clinical trials demonstrating the efficacy and effectiveness of TFP are presented. The data from the two Randomized Clinical Trials (RCT) allowed for the study of the characteristics of the subgroup of borderline personality disorder patients who have comorbid NPD/BPD. Findings on comorbidity, attachment status, capacity for mentalization, and level of personality organization of borderline patients with comorbid NPD/BPD, compared with borderline patients without comorbid narcissistic pathology (BPD), are presented. Clinical implications of the observed group differences are discussed, with a focus on refinements in the technique of TFP. Clinical case material is presented to illustrate the specific challenges posed by narcissistic patients to carrying out TFP in each phase of treatment.     

Imbalances and Impairments in Mental State Talk of Children with Internalizing and Externalizing Problems

ABSTRACT

The aims of this study were to investigate the associations between impairments and imbalances in children’s mental state talk, attachment security and abuse/neglect experiences, and to study how much of the variance in internalizing and externalizing problems was explained by mentalization problems. The sample included 100 Turkish children (M Age = 7.00 (SD = 2.01), 38% girls) referred to a outpatient psychotherapy clinic. Children were administered an attachment-based story stem task in order to code attachment security and different categories of mental state talk, including the extent of their direction (self vs other), balance, and appropriateness. Parents and teachers filled out socio-behavioral function scales. Findings indicated a significant positive association between externalizing problems and impaired mentalization. Internalizing problems were associated with mentalizing the other at the expense of one’s own mental states and underusing emotions. Attachment insecurity and adverse experiences were associated with mentalization impairments and imbalances. Finally, underuse of emotions and self-focused mental state talk predicted internalizing problems and impaired mental state talk predicted externalizing problems at trend level of significance. Qualitative analyses supported the results, which suggest that whereas children with externalizing problems suffer from severe mentalization deficits, children with internalizing problems undermentalize about themselves and emotions.     

Attachment and borderline personality disorder

The author outlines his concept of reflective function or mentalization, which is defined as the capacity to think about mental states in oneself and in others. He presents evidence to suggest that the capacity for reflective awareness in a child's caregiver increases the likelihood of the child's secure attachment, which in turn facilitates the development of mentalization in the child. He proposes that a secure attachment relationship offers the child a chance to explore the mind of the caregiver, and in this way to learn about minds; he formulates this model of the birth of the psychological self as a variation on the Cartesian cogito: "My caregiver thinks of me as thinking and therefore I exist as a thinker." This model is then applied to provide insight into some personality-disordered individuals who were victims of childhood abuse. The author proposes (1) that individuals who experience early trauma may defensively inhibit their capacity to mentalize to avoid having to think about their caregiver's wish to harm them; and (2) that some characteristics of severe borderline personality disorder may be rooted in developmental pathology associated with this inhibition. He offers evidence for and some qualifications of this model, and argues that the therapeutic effect of psychoanalysis depends on its capacity to activate patients' ability to evolve an awareness of mental states and thus find meaning in their own and other people's behavior.     

Attachment-Related Mentalization Moderates the Relationship Between Psychopathic Traits and Proactive Aggression in Adolescence

The lack of affective responsiveness to others’ mental states – one of the hallmarks of psychopathy – is thought to give rise to increased interpersonal aggression. Recent models of psychopathy highlight deficits in attachment security that may, in turn, impede the development of relating to others in terms of mental states (mentalization). Here, we aimed to assess whether mentalization linked to attachment relationships may serve as a moderator for the relationship between interpersonal aggression and psychopathic traits in an adolescent community sample. Data from 104 males and females with a mean age of 16.4 years were collected on mentalization capacities using the Reflective Functioning Scale on the Adult Attachment Interview (AAI). Psychopathic traits and aggressive behavior were measured via self-report. Deficits in mentalization were significantly associated with both psychopathic traits and proactive aggression. As predicted, mentalization played a moderating role, such that individuals with increased psychopathic tendencies did not display increased proactive aggression when they had higher mentalizing capacities. Effects of mentalization on reactive aggression were fully accounted for by its shared variance with proactive aggression. Psychopathic traits alone only partially explain aggression in adolescence. Mentalization may serve as a protective factor to prevent the emergence of proactive aggression in spite of psychopathic traits and may provide a crucial target for intervention.     

A Mother,A Baby,and Two Treatment Approaches: Discussing A Switch Case from CBT and Mentalization Perspectives

ABSTRACT

As the literature on perinatal depression and anxiety grows, there is an increased need for dialogue among theoretical approaches for mother-infant mental health. This article describes a community mental health program incorporating a range of treatment models for pregnant and postpartum women experiencing issues during the transition to parenthood. Perinatal distress can affect parenting practices, from breastfeeding to health care access, creating the need for targeted, practical, and concrete interventions. Interventions that aim to foster secure attachment relationships and mentalization capacities can also help increase maternal sensitivity and attunement and joy in caregiving, and reduce withdrawn/hostile behaviors that may be associated with perinatal distress. The article describes psychotherapy with a mother and her newborn that began from a cognitive-behavioral approach and transitioned to a psychodynamic mentalization-focused treatment. Working principles and examples of two additional components of treatment, a group psychotherapy and research measures, are discussed. The case helps demonstrate how attachment theory can inform treatment and build a bridge between alternative approaches.     

TRANSFERENCE‐FOCUSED PSYCHOTHERAPY AND MENTALIZATION‐BASED TREATMENT: BROTHER AND SISTER?

Transference‐focused psychotherapy and mentalization‐based treatment are new psychoanalytic treatment forms for borderline patients. How do these forms of treatment differ and how are they alike? What interventions do they yield in clinical practice? In the past few years two methods of psychoanalytic treatment for borderline patients have been developed: transference‐focused therapy and mentalization‐based treatment. This paper explores the similarities and differences between them, with a special focus on how the different theories lead to different interventions in clinical practice. TFP takes the central problem to be the disorder in object relations, while MBT focuses on the self as agent. Further differences concern notions of the role of aggression, the presence of mental representations and the position of the therapist. Interventions formulated by therapists of both frames of reference in response to some therapy fragments differed substantially. Both theories share a desire to develop a psychoanalytical technique suitable for borderline patients, and both stress the central importance of the handling of the transference and of working in the here‐and‐now, as well as the necessity for effect research.     

Self-report measure of parental reflective functioning: A study of reliability and validity across three samples of varying clinical risk

The Parental Reflective Functioning Questionnaire (PRFQ) provides an efficient way to measure a parent's capacity to recognize their child's mental states and to understand the relationship between underlying mental states and behavior. To date, limited work evaluates its psychometric properties beyond initial validation studies. Here we examined the reliability and validity of the PRFQ in three samples of varying clinical risk (e.g., community sample, previous mental health diagnosis, substance use disorder diagnosis). Across samples, the majority (e.g., 75%–78%) of mothers identified as White; all mothers were from the USA. We compared the PRFQ to task-based measures of mentalization, the Parent Development Interview (PDI), and measures of the parent-child relationship. The PRFQ was a reliable measure across samples, and it was associated in theoretically consistent ways with task-based measures of mentalization. Parental RF across the PDI and PRFQ were not highly correlated in a sample of mothers with substance use disorders. Existing RF measures may be tapping into a different component of the broader construct of parental reflective functioning (PRF). The PRFQ was further validated by demonstrating relationships with parent-report measures of the parent-child relationship. Taken together, these findings provide additional support for the reliability and validity of the PRFQ.     

Machiavellianism and Spontaneous Mentalization: One Step Ahead of Others

In spite of the Machiavellians' successful strategies in exploitation of others, they show cognitive deficiencies, especially reduced mind‐reading skill. Theory of mind is usually regarded as an ability to make inferences about the mental states of others and thus to predict their behaviour. In our study, we have instead emphasized a motivation‐based approach, using the concept of spontaneous mentalization. This concept is construed solely in a motivational context and not in relation to the automaticity of mind‐reading ability. It entails that people in their social relations make efforts to explore the thoughts and intentions of others and are motivated to make hypotheses about the mental state of the other person. We assumed that what is peculiar to Machiavellianism is spontaneous mentalization as a kind of motivation rather than mind‐reading as an ability. To measure spontaneous mentalization, we created a set of image stimuli and asked our participants to describe their impressions of the pictures. The results show that individual differences in spontaneous mentalization correlate positively with the scores of Machiavellianism. These results suggest that those who have a stronger motivation for putting themselves into the mind of others can be more successful in misleading and exploiting them. Further research should be carried out to clarify how spontaneous mentalization and mind‐reading ability relate to each other. Copyright © 2011 John Wiley & Sons, Ltd.     

Therapiekonzeption für traumatisierte Patienten mit schweren Persönlichkeitsstörungen

Comorbidity between severe personality disorder and posttraumatic stress disorder is a frequent clinical problem. Severe personality disorders are characterized by an impaired regulation of emotions, a low mentalization capacity and deficits in personality integration. For severe personality disorders and posttraumatic stress disorder, a variety of evidence-based treatment approaches of psychodynamic and cognitive-behavioral origin are available. However, a closer inspection of these treatment concepts shows that they do not sufficiently take the respective comorbid condition into account. No single concept is able to cover all problem areas presented by patients with this comorbidity. Therefore, an attempt is made to present an integrative psychodynamically oriented therapy concept for traumatized patients with personality disorders which contains elements from psychodynamic, cognitive-behavioral and other concepts. The phase structure of the concept clarifies the sequence hierarchy of the therapeutic interventions. The content of the five phases are: (1) safety, holding and strengthening of coping capacities, (2) emotion regulation and self-care, (3) mentalization and development of stable representations, (4) gentle trauma processing and (5) conflict-oriented psychotherapy and treatment of maladaptive relationship patterns.     

The development of borderline personality disorder--a mentalizing model

This paper describes a mentalization-based model of the development of borderline personality disorder (BPD). The model takes into account constitutional vulnerability and is rooted in attachment theory and its elaboration by contemporary developmental psychologists. The model suggests that disruption of the attachment relationship early in development in combination with later traumatic experiences in an attachment context interacts with neurobiological development. The combination leads to hyper-responsiveness of the attachment system which makes mentalizing, the capacity to make sense of ourselves and others in terms of mental states, unstable during emotional arousal. The emergence of earlier modes of psychological function at these times accounts for the symptoms of BPD. The model has clinical implications and suggests that the aim of treatment is not only to encourage development of mentalizing but also to facilitate its maintenance when the attachment system is stimulated.     

The relationship of maternal mentalization and executive functioning to maternal recognition of infant cues and bonding

The study examined associations between maternal mentalization ability, executive functioning, recognition of infant cues, and bonding in a non‐clinical sample of mothers. It employed a correlational design. Sixty‐four mothers of young infants completed assessments of mentalization ability, executive functioning, and bonding. Photographs of infant facial expressions were utilized to assess ability to recognize infant cues of emotion, but this was not found to correlate with either maternal mentalization or executive functioning ability. Whilst a trend towards a significant positive relationship between mothers' cued ability to attribute mental states and their ability to recognize infant facial expressions was observed, no significant relationships were found between bonding scores and performance on the executive functioning and mentalization measures. The present study contributes to our current understanding of the influence of maternal cognitive factors, specifically mentalization and executive functioning, on the development of the mother–infant relationship. Future research, methodological issues, and clinical and theoretical implications are discussed.     

Dialectical behaviour therapy skills training compared to standard group therapy in borderline personality disorder: A 3-month randomised controlled clinical trial

Dialectical behaviour therapy (DBT) has proven to be an effective treatment in borderline personality disorder (BPD). However, the effectiveness in BPD of DBT skills training (DBT-ST) alone is not known. This study aimed at comparing the efficacy of DBT-ST and standard group therapy (SGT) for outpatients with BPD. Sixty patients meeting the DSM-IV diagnostic criteria for BPD, as assessed by two semi-structured diagnostic interviews, were included in a 3-month, single-blind randomised controlled trial. A total of 13 weekly group psychotherapy sessions of 120 min of either SGT or DBT-ST were conducted. Assessments were carried out every 2 weeks by two blinded evaluators. Observer-rater, self-report scales and behavioural reports were used as outcome measures. DBT-ST was associated with lower dropout rates, 34.5% compared to 63.4% with SGT. It was superior to SGT in improving several mood and emotion areas, such as: depression, anxiety, irritability, anger and affect instability. A reduction in general psychiatric symptoms was also observed. Three-months weekly DBT-ST proved useful. This therapy was associated with greater clinical improvements and lower dropout rates than SGT. DBT-ST seems to play a role in the overall improvement of BPD seen with standard DBT intervention. It allows straightforward implementation in a wide range of mental health settings and provides the additional advantage that it is cost effective.     

“I Will Fear no Evil,for I Am with Me”: Mentalization-Oriented Intervention with PTSD Patients. A Case Study

Post traumatic stress disorder (PTSD) patients are described as suffering from a collapse of mentalization—the inability to understand and interpret their own behavior and that of others as emanating from intentional mental states. The present paper proposes an integrative focused intervention, called “traumatic mentalization change”, to improve and strengthen the mentalization abilities of PTSD patients. With the assistance of the therapist, patients learn how to embed their present self-states within their retrieved memories of the traumatic event and thus to change their traumatic narrative. These present selfstate images enrich the patients’ narratives with the emotional needs that were missing during the traumatic event by addressing mistaken attributions regarding these memories. In this way, the traumatic narrative changes, and the devastating selffeelings experienced during the original traumatic event are reduced. We demonstrate this intervention with a case study of a veteran PTSD patient who suffered from PTSD for 10 years after being involved in a terrorist attack. The neuro-clinical and clinical implications are discussed.