Development and validation of the Mentalizing Emotions Questionnaire: A self-report measure for mentalizing emotions of the self and other

Mentalizing describes the ability to imagine mental states underlying behavior. Furthermore, mentalizing allows one to identify, reflect on, and make sense of one's emotional state as well as to communicate one's emotions to oneself and others. In existing self-report measures, the process of mentalizing emotions in oneself and others was not captured. Therefore, the Mentalizing Emotions Questionnaire (MEQ; current version in German) was developed. In Study 1 (N = 510), we explored the factor structure of the MEQ with an Exploratory Factor Analysis. The factor analysis identified one principal (R2 = .65) and three subfactors: the overall factor was mentalizing emotions, the three subdimensions were self, communicating and other. In Study 2 (N = 509), we tested and confirmed the factor structure of the 16-items MEQ in a Confirmatory Factor Analysis (CFI = .959, RMSEA = .078, SRMR = .04) and evaluated its psychometric properties, which showed excellent internal consistency (α = .92 - .95) and good validity. The MEQ is a valid and reliable instrument which assesses the ability to mentalize emotions provides incremental validity to related constructs such as empathy that goes beyond other mentalization questionnaires.

[Mentalizing the pain-Implementation of a mentalization-based manual for the therapeutic support of pain patients.]

Chronic pain is usually a complex disorder with possible indications for an impairment at the personality functioning level. Guidelines recommend a multiprofessional interdisciplinary treatment approach. Based on the alternative model of personality disorders of the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) and the International Classification of Diseases, eleventh revision (ICD-11), an integrative manual was designed to exactly fit the interdisciplinary multimodal treatment of patients of the day clinic for pain at the orthopedic clinic of the University Hospital Heidelberg. The treatment manual specifically promotes various areas of personality functioning levels, such as emotion regulation, identity, empathy and relationships through individual and group interventions against the background of a mentalization-based therapeutic attitude. A focus group was used to qualitatively evaluate the implementation of the new treatment manual. With good applicability of the manual and satisfaction of the therapy team, a common language for the interdisciplinary team could be created to improve the therapeutic interaction.

Mediators of Outcome in Trauma-Focused Psychotherapy with Youth: A Systematic Review

This article aimed to provide a systematic narrative synthesis of existing studies on the mediators of change in psychotherapy with adolescents (10-19 years) and transition age youth (TAY) (20-29 years) who have experienced trauma-related symptoms or posttraumatic disorder. Additionally, we were interested in identifying psychotherapy-, trauma type-, and clients' age- and gender-specific mediators of treatment outcome. Following the preferred reporting items for systematic reviews and meta-analyses, a total of 3,723 studies published in PubMed and PsycINFO databases were screened against inclusion criteria, revealing 15 eligible studies. No studies with only TAY were found; therefore, all results were limited to therapy with adolescents. Cognitive mediators were tested in 66% of selected studies, followed by parents/family-related, mental-health-related, therapy-related, and behavioral mediators. Moderate evidence was found for posttraumatic cognitions, whereas therapeutic alliance seemed to be a promising candidate for future research. Striking absence of non-cognitive-behavioral therapy interventions, emotional and adolescent-specific mediators, as well as studies with males and in non-Western societies was evident. Future original studies would benefit from applying methodological rigor in respect to mediation testing.

Enhancing mentalization by specific interventions within mentalization-based treatment of adolescents with conduct disorder

Objective

Mentalization is discussed as a mechanism of change in psychotherapy due to its positive effects on psychological functioning. In order to specifically apply mentalization-based interventions, a better understanding of the relationship between interventions and in-session mentalization is needed. The study aimed to explore the association between interventions and effective mentalizing.

Method

Fifteen therapy sessions of three therapies with male adolescents with conduct disorder were transcribed and rated with the Reflective Functioning (RF) Scale and a newly developed Mentalization-based Treatment (MBT) intervention coding manual. The coded interventions were categorized into intervention levels according to the MBT manual. Fisher's exact tests were performed to test differences in frequencies of interventions in high-RF sequences (RF score ≥ 4) compared with remaining therapy sequences (RF score ≤ 3).

Results

Specific MBT interventions such as demand questions, affectelaboration, empathic validation, change of subject, challenge, patienttherapist relation and mentalizing for the patient were related to effective mentalizing. Moreover, intervention levels such as supportive & empathic, basic- mentalizing & affect mode and relational mentalizing were positively associated with effective mentalizing.

Conclusion

MBT interventions seem to promote effective mentalizing at various intervention levels. Interventions that enhance effective mentalizing seem to be patient specific. In line with MBT theory, their effect on effective mentalizing might depend on various variables, such as the patients' arousal and pre-mentalizing mode.

The relationship between epistemic stance, mentalizing, paranoid distress and conspiracy mentality: an empirical investigation

Epistemic stance, comprising epistemic trust, mistrust, and credulity, and the closely related construct of mentalizing have been related to paranoid ideation and conspiracy mentality. All phenomena are common in the general population and may become clinically and societally relevant at an extreme expression by influencing an individual's positioning towards socially transmitted information possibly as far as complete social detachment or attachment to extremist views. Herein, an individual's experienced distress may play an important role, which has however largely been neglected in empirical research. Thus, this study aims to empirically investigate the effect of epistemic stance on a clinically relevant aspect of paranoid ideation, namely paranoid distress. We assume that epistemic stance will be associated with paranoid distress, but that this association will be mediated by mentalizing. Moreover, we assume that epistemic stance will be indirectly associated with conspiracy thinking via paranoid distress. Data of 595 participants (mean age = 43.05; SD = 13.87; female = 48.32%, male = 51.18%, diverse = 0.51%) were collected via self-report questionnaires through an online-based cross-sectional study. Structural equation modeling was performed for data analysis. As expected, epistemic mistrust was associated with paranoid distress via mentalizing deficits. Unexpectedly, epistemic trust was associated with more paranoid distress. Indirectly, epistemic trust was associated with conspiracy mentality via paranoid distress. Findings partially confirmed the hypothesized associations. Mentalizing may be a target for reducing distress associated with a distrusting epistemic stance. Epistemically trusting individuals with high paranoid distress may turn to conspiracy theories for regulation.

["IThink it's Good that they Choose who they want to be Stroked by" -The Support Quality of Animal-BasedTherapy]

For Adolescents with personality impairments it's often difficult to accept therapy offers. Personality impairment may be preceded by (early childhood) trauma, which undermines trust in others.Thus, adolescents with traumatic experience often have limited motivation to start psychotherapy, also due to the greater need for autonomy and the process of detachment in this age phase. However, adolescence is a particularly sensitive period, as personality impairments may consolidate and personality disorders (PD) develop. To address low trust and lowmotivation in adolescents with high risk for or already full PD an animal-assisted group therapy adjunct to individual mentalization-based therapy was developed and piloted. Two groups with a total of eleven patients each were conducted, four of whom agreed to talk about their experiences with animal-assisted therapy in an interview after completion of therapy. Interviews were analyzed qualitatively and evaluated with regard to the aspects of what the adolescents liked and disliked, what expectationsweremet or unmet, andwhat effects the adjunct intervention had on the adolescents' therapeutic success.The categorized statements are discussed related to the theories of human-animal interaction according to Hediger et al. (2019) and a new hypothesis about animals as teambuilding catalysts could be established. In sum, alpacas were perceived suitable as therapy animals for adolescents with personality impairments.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): a feasibility study

Conduct disorder (CD) is a common psychiatric disorder in youth characterized by persisting norm-violating or aggressive behavior. Considering high individual and societal burden, feasible and effective psychotherapeutic treatment is desirable. Yet, treatments and research in this patient group are scarce. This study investigates the feasibility of mentalization-based treatment for adolescents with CD (MBT-CD) in terms of acceptability of MBT-CD and scientific assessments by participants as well as necessary organizational resources to conduct a consecutive randomized controlled trial (RCT). Recruitment, adherence and treatment session numbers were descriptively analyzed. Treatment evaluation interviews were qualitatively analyzed. A subset of sessions of therapists without prior MBT experience was rated for MBT adherence. Quantitative data were used to plan a consecutive RCT. Pre to post treatment changes in diagnosis and self-reported aggression, mentalizing and personality functioning were preliminarily analyzed. N = 45 adolescents with CD were recruited. 43% dropped out. Acceptance of scientific assessments was somewhat lower than therapy adherence (questionnaires filled out by ~ 80% of adolescents in treatment), and low at follow-up (25% of treatment completers). Mean session number was 30.3. Most treatment completers were satisfied with MBT-CD. Referrals mainly came from child and youth services and psychiatry. Nine of 16 sessions rated for MBT adherence were adherent. A priori sample size estimation for a prospective RCT with a drop-out rate of 43% yielded a sample of N = 158 to detect an effect f = .15 with 80% power in a repeated measures ANOVA. Pre-post analyses revealed diagnostic improvement in 68%. Of self-reported data, empathy pathology improved. Findings provide a sound basis for a consecutive feasibility and pilot RCT. TRIAL REGISTRATION: Clinicaltrials.gov, registration number NCT02988453, November 30, 2016, https://clinicaltrials.gov/ct2/show/NCT02988453.

[German S3 guidelines on borderline personality disorder]

Research on the understanding and especially on the treatment of borderline personality disorder (borderline PD) has made considerable progress in recent years, so that evidence-based German treatment guidelines have now been produced for the first time. This article highlights the development as well as the main content priorities and recommendations of the guidelines: first, the recommendations on the diagnostics are presented and in this context the upcoming changes to the International Classification of Diseases 11th reversion (ICD-11) are also explained. Subsequently, the most important recommendations on guideline-compliant psychotherapy, pharmacotherapy and treatment settings are presented. Finally, the recommendations concerning relatives (or other significant persons for people with borderline PD) as well as parenthood and borderline PD are presented.

Is parental depression related to parental mentalizing? A systematic review and three-level meta-analysis

This systematic review and meta-analysis is aimed to summarize the state of research on the relation between parental depression and parental mentalizing. To account for the multifaceted nature of parental mentalizing, several conceptualizations and measures were included and compared. The last database search was conducted on March 13, 2023. Using three-level meta-analytic modelling, we analyzed a total of 12,665 participants from 63 studies with 233 effect sizes. Taken together, higher depression was only weakly associated with lower mentalizing (r = -0.06). Specifically, parents with higher depression scored lower on questionnaire measures of parental reflective functioning (r = -0.11). No significant correlations were found for interview measures of parental reflective functioning, the observational and interview measure of mind-mindedness, or insightfulness. The data showed substantial heterogeneity. The mean effect size for self-reported pre-mentalizing (r =  -0.23 for reverse-coded subscale scores) was significantly stronger compared to other self-report subscales. In studies including parents with diagnosis and controls, there was limited evidence suggesting a larger negative correlation between depression, mind-mindedness, and insightfulness. Therefore, more research is needed in clinical samples. Due to their correlational nature, our results do not allow causal inferences. Future studies should target moderators that explain variability (e.g., comorbid psychological problems, coparenting, child behavior).

[On the State of Training in Parent-Infant/Toddler Psychotherapy in Germany]

Regulation disorders in early childhood and postpartum mental disorders of parents can be effectively treated by interventions that involve parents and child (so-called parent-infant psychotherapy, PIP). Availability of PIP in routine care remains low, even though the intervention is in high demand. This study aims to map the current situation of psychotherapy training in PIP in Germany, to record existing obstacles from the perspective of the institutes, and to obtain indications for improving training. Contact persons of training institutes all over Germany were invited to participate in an online survey. N = 95 persons answered questions about possible training in PIP and related advantages and hurdles as well as conditions for a future implementation. Nineteen (22.4 %) of the institutions indicated that PIP was part of their training concept. In 84.2 % of the cases this was aimed at child and adolescent psychotherapists. In 63.6 % of the institutes PIP was treated comprehensively. On average, 2.55 barriers were perceived, most frequently of an organizational nature. 75.9 % of the institutes that did not yet offer PIP would be willing to do so in the future under at least one condition. Among those conditions, information on PIP curricula and specific training content was most frequent (40.7 %).The low implementation of PIP in training seems to be mainly due to barriers of an organizational nature that can be overcome by some simple means, such as the dissemination of model curricula.

[The Personality Inventory for ICD-11 (PiCD): Reliability and Validity of the German Version in a Clinical and Non-Clinical Sample]

The 11th version of the International Statistical Classification of Diseases and Related Health Problems (ICD-11) marks a paradigm shift in the diagnosis of personality disorders: In the near future, their classification will no longer be categorical, but dimensional along the severity of personality impairments and optionally regarding the presence of maladaptive personality traits. This study examines the reliability and validity of the German version of the Personality Inventory for ICD-11 (PiCD), a questionnaire designed to assess ICD-11 maladaptive personality domains, in a clinical and nonclinical sample (N=939). The factor structure of the PiCD was examined using Exploratory Factor Analysis (EFA) and showed a tendency for a four-factor model (Negative Affectivity, Dissociality, Detachment, and a bipolar factor Disinhibition-Anankastia). The subscales of the PiCD demonstrated acceptable to excellent reliability coefficients with Cronbach's α (0.79 - 0.89) and McDonald's ω (0.76 - 0.90). Convergent and discriminant validity were examined in conjunction with other questionnaires and were found to be satisfactory. The results suggest that the German version of the PiCD is a reliable and largely valid measurement instrument for assessing ICD-11 maladaptive personality traits. However, further research on factor structure, appropriate cut-off as well as norm values is needed.

Transactional Relations between Child Functioning and Parenting Stress in the First Years of Life: A Longitudinal Study among Psychosocially Burdened Families

INTRODUCTION

Previous research reported transactional relations between child functioning and parenting stress. There is limited evidence whether a transactional developmental model also fits children below the age of 12 months, especially in psychosocially burdened families. This study aims to test the fit of a transactional model during the first 3 years of life and examines whether the model differs between families with low and high psychosocial burden.

METHODS

A total of 302 psychosocially burdened families were observed over 3 years at age 4, 12, 24, and 36 months. Child behavioral problems and parenting stress were assessed via self-report while psychosocial burden was assessed via external rating at baseline. Cross-lagged panel analysis was used to investigate the fit of a transactional model.

RESULTS

A transactional model fitted the data significantly better (Δχ2 = 81.87, p < 0.001) than an autoregressive model reaching acceptable to good fit indices (CFI = 0.96, RMSEA = 0.09). The model indicated moderate stability within and reciprocal effects between child behavioral problems and parenting stress from age 12 to 36 months. From age 4 to 12 months, parenting stress predicted child behavioral problems but not vice-versa. Model fit indices and transactional relations did not substantially differ between families with low and high psychosocial burden, except for child effects on parenting stress during the first year of life, which were only evident in higher burdened families.

CONCLUSION

Transactional relations among child and parent variables are evident in the first 3 years of life. Child effects in the first year of life may be restricted to highly psychosocially burdened families. Future research may focus on potential mediating variables such as parental sensitivity or contextual variables like significant life events. Targeted prevention strategies should be adapted to the level of psychosocial burden to account for the differing transactional relations.

Improving working relationships with families in German early childhood interventions home visitors: a quasi-experimental training study

BACKGROUND

Home visitation services within German Early Childhood Interventions (ECI) for families with a child aged 0-3 are mainly provided by frontline pediatric nurses and family midwifes. Home visitors are often challenged by difficult interactions with families. Mentalizing, the ability to understand mental states of oneself and others, is a key skill for building effective working relationships, which in turn positively affect intervention outcomes. The aim of this study was to investigate if a mentalizing skills training offered to home visitors active in German ECI contributes to continued professional development. We investigated, whether the training positively affected the quality of the working relationships with families as well as home visitors' empathy, self-efficacy, and mentalizing.

METHODS

To test the effects of a single day mentalizing skills training on the working relationship in N = 73 ECI home visitors, we used a quasi-experimental design with repeated measures (T0, T1, T2, T3) across seven weeks in order to assess immediate change from baseline (T0) after the training (T2) and stability of changes at follow up (T3). A literature-based intervention was implemented before the training to estimate possible repeated measurement and expectational effects (T1). Primary outcome was the quality of the working relationship experienced by the home visitors. Secondary outcome criteria were empathy, work-related self-efficacy, self-reported and observer-rated mentalizing.

RESULTS

Significant positive change in the working relationship quality was observed at T2 and at T3. Results on the secondary outcomes were less consistent, with data indicating improvement in empathy and increase on some but not all components of mentalizing.

CONCLUSIONS

This study provides preliminary evidence that brief mentalizing skills trainings may be an effective method for continuous professional qualification in frontline ECI home visitors who afterwards, experience better working relationships with families. Thus, training participation may positively impact efficacy and implementation of home visitations in ECI.

An exploratory study on how attachment classifications manifest in group psychotherapy

Recently, attachment-informed researchers and clinicians have begun to show that attachment theory offers a useful framework for exploring group psychotherapy. However, it remains unclear whether patients with differing attachment classifications would behave and speak in distinct ways in group therapy sessions. In this study, we conducted an exploratory analysis of the discourse of patients in group therapy who had independently received different classifications with gold standard interview measures of attachment in adults. Each patient participant attended one of three mentalization-based parenting groups. Before treatment, the Adult Attachment Interview (AAI) or the Parent Development Interview (PDI) were administered to each patient, and interviews were transcribed and coded to obtain the patient's attachment classification. Groups included 2, 5, and 5 patients, respectively, and any session was led by at least two co-therapists. A total of 14 group sessions were transcribed verbatim. Sessions were analysed through a semi-inductive method, in order to identify markers that would typify patients of different attachment classifications in session. Through transcript excerpts and narrative descriptions, we report on the differing ways in which patients of different attachment classifications communicate in group psychotherapy, with the therapist and with each other. Our work provides useful information for group therapists and researchers regarding how differences in attachment status may play out in group sessions.

The in-session discourse of unresolved/disorganized psychotherapy patients: An exploratory study of an attachment classification

The Unresolved/disorganized (U/d) attachment classification has generated considerable interest among clinicians. This is in part based on its empirical associations with adult mental health, parenting practices, and treatment outcomes. Despite decades of theorizing, however, we have little empirical information regarding how patients with a U/d classification assigned by accredited coders actually behave or speak in psychotherapy sessions. Here, we take a step towards bridging this gap by reporting our observations of the psychotherapy session transcripts of 40 outpatients who were independently classified as U/d on the Adult Attachment Interview (AAI), the gold standard measure of adult attachment research. These patients were extracted from a larger sample of 181 and compared to others without a U/d classification. In this paper, we discuss two different discourse styles associated with a U/d classification. Some U/d patients did not seem to sufficiently elicit the therapist’s endorsement of what they said. For example, they did not justify their claims with examples or explanations, or did not consider others’ intentions or experiences. Other U/d patients were credible, but left the listener uncertain as to the underlying point of their discourse, for example, by glaringly omitting the consequences of their experiences, or interrupting their narratives mid-way. In the discussion, we place these observations in the context of recent thinking on attachment and epistemic trust, and discuss how this study may form the basis for future quantitative studies of psychotherapy.

The ICD-11 classification of personality disorders: a European perspective on challenges and opportunities

The 11th revision of the World Health Organization (WHO) International Classification of Diseases (ICD-11) includes a fundamentally new approach to Personality Disorders (PD). ICD-11 is expected to be implemented first in European countries before other WHO member states. The present paper provides an overview of this new ICD-11 model including PD severity classification, trait domain specifiers, and the additional borderline pattern specifier. We discuss the perceived challenges and opportunities of using the ICD-11 approach with particular focus on its continuity and discontinuity with familiar PD categories such as avoidant PD and narcissistic PD. The advent of the ICD-11 PD classification involves major changes for health care workers, researchers, administrators, and service providers as well as patients and families involved. The anticipated challenges and opportunities are put forward in terms of specific unanswered questions. It is our hope that these questions will stimulate further research and discussion among researchers and clinicians in the coming years.

Theories of Change and Mediators of Psychotherapy Effectiveness in Adolescents With Externalising Behaviours: A Systematic Review

BACKGROUND

Externalising behaviours are becoming a remarkably prevalent problem during adolescence, often precipitating both externalising and internalising disorders in later adulthood. Psychological treatments aim to increase the social functioning of adolescents in order for them to live a more balanced life and prevent these negative trajectories. However, little is known of the intervening variables and mediators involved in these treatments' change mechanisms. We conducted a systematic review, exploring the available evidence on mediators of psychological treatments for externalising behaviours and symptoms amongst adolescents (10 to 19 years old).

METHODS

A systematic search was performed on Medline and PsycINFO databases, which identified studies from inception to February 23, 2020. Eligible studies included randomised controlled trials that enrolled adolescents with externalising symptoms and behaviours as, at least, one of the primary outcomes. A group of 20 reviewers from the COST-Action TREATme (CA16102) were divided into 10 pairs. Each pair independently screened studies for inclusion, extracted information from the included studies, and assessed the methodological quality of the included studies and the requirements for mediators, following Kazdin's criteria. Risk of bias of RCTs was assessed by the Mixed Methods Appraisal Tool. Extracted data from the included studies were reported using a narrative synthesis.

RESULTS

Following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PRISMA), after removing duplicates, 3,660 articles were screened. Disagreements were resolved by consensus. In a second stage, 965 full-text articles were assessed for eligibility. A total of 14 studies fulfilled all inclusion criteria. The majority were related to systemic psychological treatment approaches. Two types of mediators were identified as potentially being involved in the mechanisms of change for better social improvements of adolescents: to increase healthier parent-adolescent relationships and parental discipline. However, there were significant and non-significant results amongst the same mediators, which led to discussing the results tentatively.

CONCLUSIONS

Family variables were found to be the largest group of investigated mediators, followed by relational, behavioural, and emotional variables. No cognitive or treatment-specific mediators were identified. Both adequate behavioural control of adolescents' peer behaviour and a better positive balance in their relationships with their parents seemed to buffer the effects of externalising behaviours in adolescents. Several methodological limitations concerning mediation testing design, outcome measures, and mediator selection have been identified.

ETHICS AND DISSEMINATION

Ethical approval was not required. PROSPERO registration number: CRD42021231835.

Learning from mothers who received focused parent-infant psychotherapy for the treatment of their child's regulatory disorders

OBJECTIVE

Gaining a deeper understanding of how focused parent-infant psychotherapy (fPIP) works by asking mothers about their experiences.

METHOD

Purposeful sampling was used to select participants who before had participated in an RCT on fPIP. Nine mothers of infants with early regulatory disorders who had received fPIP were interviewed. Eight cases received full-protocol treatment, one case was a treatment drop-out. Semi-structured interviews were audio-recorded, transcribed verbatim and analyzed applying grounded theory methodology.

RESULTS

Seven major categories evolved: (1) engaging in therapy while maintaining autonomy, (2) relating to an emotionally responsive therapist and resolving ruptures, (3) involvement of partners in therapy facilitates multiple perspectives, (4) understanding the meaning of the child's signals and increasing acceptance of difficult behaviors, (5) feeling supported by advice that is attuned to the families' needs, (6) insight into parental contributions to the child's problems and (7) feeling strengthened as a mother and recognizing one's own needs.

CONCLUSION

Findings highlight which aspects of fPIP mothers find most helpful and most challenging. Aspects that compromised the change process seemed related to the specific needs of this population and therapeutic setting. The results may guide therapists and inspire future development in interventions for treating infant regulatory disorders.

In-Session-Reflective-Functioning in Anorexia Nervosa: An Analysis of Psychotherapeutic Sessions of the ANTOP Study

OBJECTIVE

Previous research suggests that patients with anorexia nervosa (AN) show an impaired capacity to mentalize (reflective functioning, RF). RF is discussed as a possible predictor of outcome in psychotherapeutic processes. The study aimed to explore RF in sessions of patients with AN and its association with outcome and type of treatment.

METHODS

A post-hoc data analysis of selected cases from a randomized trial on outpatient psychotherapy for AN was conducted. Transcripts from 84 sessions of 28 patients (early phase, middle phase, and end of treatment) were assessed using the In-Session-Reflective-Functioning-Scale [14 cognitive-behavior therapy, enhanced (CBT-E); 14 focal psychodynamic therapy (FPT); 16 with good, 12 with poor outcome after 1 year]. Relations between the level of RF, type of treatment, and outcome were investigated using mixed linear models. Additionally, associations with depressive symptoms, weight gain, and therapeutic alliance were explored.

RESULTS

Mean in-session RF was low. It was higher in FPT when compared to CBT-E treatments. The findings point to an association between RF increase and a positive outcome. An increase in BMI in the first half of treatment was associated with higher subsequent in-session RF. There was no association between RF and depressive symptoms or the therapeutic alliance.

DISCUSSION

Patients with AN show a low capacity to mentalize in sessions, which seems to be at least partly dependent on the degree of starvation. The results suggest a possible relationship between an increase in in-session RF and outcome, which has to be replicated by further studies.

Parental Mental Illness, Borderline Personality Disorder, and Parenting Behavior: The Moderating Role of Social Support

PURPOSE OF REVIEW

Parental mental disorders, particularly borderline personality disorder (BPD), impair parenting behavior. Consequently, the children exhibit an elevated risk for psychopathology across their lifespan. Social support for parents is thought to moderate the relationship between parental mental illness and parenting behavior. It may dampen negative effects and serve as starting point for preventive interventions. This paper provides a literature overview regarding the impact of social support on the sequelae of parental mental illness and BPD for parenting behavior.

RECENT FINDINGS

Current literature highlights the increased burden of families with a mentally ill parent and associated changes in parenting behavior like increased hostility and affective dysregulation, especially in the context of parental BPD. Literature further demonstrates the powerful impact of social support in buffering such negative outcomes. The effect of social support seems to be moderated itself by further factors like socioeconomic status, gender, or characteristics of the social network. Social support facilitates positive parenting in mentally ill parents and may be particularly important in parents with BPD. However, social support is embedded within a framework of influencing factors, which need consideration when interpreting scientific results.

Clinical Implementation and Evaluation of Three Implementation Interventions for a Family-Oriented Care for Children of Mentally Ill Parents (ci-chimps): Study Protocol for a Randomized Controlled Multicenter Trial

BACKGROUND

In Germany, approximately three million children under the age of eighteen have a mentally ill parent. These children are at an increased risk of developing a mental illness themselves (1) as well as a physical illness (2). While research has identified numerous evidence-based family-oriented interventions, little is known about how to implement such interventions effectively and efficiently in clinical practice in Germany. This implementation study (ci-chimps) evaluates three clinical implementation projects with three different implementation interventions for the optimal implementation of the tailored family-oriented preventive and therapeutic interventions in the CHIMPS-NET (children of mentally ill parents-research network) with an implementation model for children of mentally ill parents.

METHODS

A two-group randomized controlled multicenter trial will examine changes in family-oriented practice and aspects of implementation at baseline as well as at 12- and 24-months follow-up. The CHIMPS-Network consists of 20 clinical centers. The centers in the intervention group receive the support of all of the three implementation interventions: (1) optimal pathways to care, (2) education and a training program for professionals, and (3) systematic screening for children. The centers in the control group do not receive this specific implementation support.

DISCUSSION

While we know that children of mentally ill parents are an important target group to be addressed by preventive and therapeutic interventions, there is often a lack of structured implementation of family-oriented interventions in clinical practice in Germany. Using a randomized controlled multicenter trial design with a large and wide-ranging sample (clinics for adult psychiatry and clinics for child and adolescent psychiatry, university clinics and clinics at the real health care) will provide a robust understanding of implementing family-oriented changes in German clinical practice.

TRIAL REGISTRATION

The CHIMPS-NET-study was registered with the German Clinical Trials Register on 2019-12-19 (DRKS00020380) and with Clinical Trials on 2020-4-30 (NCT04369625), the ci-chimps-study was registered with the German Clinical Trials Register (DRKS00026217) on 2021-08-27, the Clinical Trials registration is in review process.

Transdiagnostic Mechanisms of Mental Health During the COVID-19 Pandemic on Adults and Families in Germany: Study Protocol of a Cross-Sectional and 1-Year Longitudinal Study

Background: Since the outbreak of COVID-19 pandemic, psychological distress is increased. Transdiagnostic mechanisms, including trauma, personality functioning, mentalizing and emotion regulation are considered relevant to the development and maintenance of mental health problems and therefore may play a role in individuals’ reactions to the pandemic.

Aim: To identify moderating and mediating factors associated with pandemic-related distress and mental health problems in adults and families, we aim to investigate the interactions of interpersonal trauma (childhood trauma and domestic violence), psychological capacities (personality functioning, mentalizing and emotion regulation) and pandemic-related adversity on psychological distress during the COVID-19 pandemic. Furthermore, we aim to investigate behavioral and cognitive consequences of the pandemic (e.g., media consumption, vaccination status, conspiracy beliefs).

Methods: Using an online-based cross-sectional and longitudinal design, we will investigate a sample of adult participants recruited via online platforms in German-speaking countries over the course of 1 year with four measurements points via self-report instruments (personality functioning: PID5BF +; mentalizing: MentS, PRFQ; emotion regulation: DERS-SF; mental health problems: PHQ-9, GAD-7; a composite pandemic-related stress score). Structural equation and multi-level modeling will be performed for data analyses.

Implications: This study will provide data on the moderating and mediating effects of trauma, personality functioning and mentalizing during the pandemic in a large community sample, particularly on vulnerable groups like families. Identifying transdiagnostic mechanisms of psychopathology in the course of a pandemic crisis may provide valuable insight for the development of pre- and intervention measures for potential psychological distress during and post the pandemic.

[Bifocal perspective in the work with families with mentally ill parents]

BACKGROUND

Mentally ill parents pose a risk factor for the transgenerational transmission of mental disorders. Contemporary psychiatry mainly focuses on the individual and patients are not always recognized as being parents.

OBJECTIVE

The development and evaluation of a training program for mental health professionals to support a family orientation in psychiatric treatment by using a bifocal perspective, which keeps an eye on the index patient and the family with a focus especially on children, are presented.

METHODS

In order to establish the bifocal perspective in attitudes, knowledge and skills, a half-day training program, consisting of a lecture and a seminar was developed. This was carried out as part of the Children of Mentally Ill Parents -Research Network (CHIMPS-NET) consortium at seven locations in Germany in the respective adult, pediatric and adolescent departments of psychiatry. The needs were evaluated before the training using an online questionnaire. The implementation was accompanied by a qualitative analysis of memory protocols of the trainers.

RESULTS AND DISCUSSION

The training could be successfully carried out with 120 participants, whereby the target of a comprehensive training of the complete personnel across occupational groups could not be realized, also partly due to the pandemic, and the exercising elements of training could not all be utilized. The evaluation of the questionnaire, which was completed by approximately 50% of the participants showed that the group of participating psychologists and physicians already had a strong family orientation. The qualitative analysis of protocols from all locations documented a strong need for networking across institutions and clear standard procedures, e.g. in dealing with child maltreatment.

Neural response to aggressive and positive interactions in violent offenders and nonviolent individuals

BACKGROUND

Due to its severe negative consequences, human violence has been targeted by a vast number of studies. Yet, neurobiological mechanisms underlying violence are still widely unclear and it seems necessary to aim for high ecological validity to learn about mechanisms contributing to violence in real life.

METHODS

The present functional magnetic resonance imaging (fMRI) study investigated the neurofunction of individuals with a history of violent offenses compared with that of controls using a laboratory paradigm requesting individuals to empathically engage in videos depicting provocative aggressive and positive social interactions from a first-person perspective.

RESULTS

The contrast of aggressive vs. positive scenarios revealed midbrain activation patterns associated with caudal periaqueductal gray (PAG) in violent offenders; In controls, the rostral PAG was involved. Additionally, only in controls, this contrast revealed an involvement of the amygdaloidal complex. Moreover, in violent offenders the contrast of positive vs. aggressive situations revealed an involvement of areas in the insula, post-central gyrus and anterior cingulate cortex.

CONCLUSIONS

Our results support findings on the differential role of PAG subdivisions in response to threat and point to altered processing of positive social interactions in violent offenders. They further support the notion that changes in PAG recruitment might contribute to violent individuals "taking action" instead of freezing in case of threatening situations.

Introduction to Mentalization-Based Approaches for Parents, Children, Youths, and Families

Family members mentalize when they try to understand each other's behavior on the basis of intentional mental states. This article aims to introduce and briefly describe how the concept of mentalization can provide a useful framework for clinicians to understand psychopathology of children, youths, and families. The authors further outline how mentalization-based techniques and interventions can be applied to build epistemic trust and to reestablish mentalizing in families by presenting clinical vignettes of initial sessions from various clinical settings in the United Kingdom and Germany. The article concludes with a brief summary about the current evidence for mentalization-based interventions with children, adolescents, and families and provides an outlook for future clinical and research work.

Understanding and breaking the intergenerational cycle of abuse in families enrolled in routine mental health services: study protocol for a randomized controlled trial and two non-interventional trials investigating mechanisms of change within the UBICA II consortium

Background

Parents’ mental illness (MI) and parental history of early life maltreatment (ELM) are known to be significant risk factors for poor parenting while poor parenting is a crucial mediator of the intergenerational continuity of child maltreatment. Hence, maltreatment prevention programs for families with an MI parent, which pay particular attention to experiences of ELM in the parent, are urgently needed. Parental mentalizing was previously found to mediate successful parenting. Interventions aimed at improving the parental mentalizing capacity reduced maltreatment risk in parents. The aim of the present study is to investigate the effectiveness of a mentalization-based parenting-counseling in acutely mentally ill parents currently treated at a psychiatric hospital.

Methods

Mentalization-based parenting-counseling (MB-PC) vs. enhanced standard clinical care (SCC+) will be administered in a cluster-randomized-controlled trial (RCT). Patients treated at psychiatric hospitals with children between 1.5 and 15 years will be included in the trial. MB-PC will be administered as a 12-h combined individual and group program enriched by social counseling (over a course of 5 weeks) as add-on to standard clinical care, while the control condition will be standard clinical care plus a 90-min psychoeducation workshop on positive parenting. Primary efficacy endpoint is self-reported parenting practices at follow-up. Embedded within the RCT will be two sub-studies investigating social cognition and dyadic synchrony as biobehavioral mechanisms of change.

Discussion

The main goal of the present study is to investigate ways to break the intergenerational continuity of maltreatment by assessing the benefits of a prevention program which aims at improving parenting in vulnerable mothers and fathers. MB-PC is a short, low-cost intervention which can be delivered by nurses and social workers and is applicable to MI patients with children with a broad range of diagnoses. If it is shown to be effective, it can be directly implemented into standard psychiatric hospital care thereby providing help to prevent child maltreatment.

Trial registration

German Clinical Trials Register DRKS00017398. Registered on 5 July 2019

Mediators and Theories of Change in Psychotherapy for Young People With Personality Disorders: A Systematic Review Protocol

Background: Personality disorders (PDs) are a severe health issue already prevalent among adolescents and young adults. Early detection and intervention offer the opportunity to reduce disease burden and chronicity of symptoms and to enhance long-term functional outcomes. While psychological treatments for PDs have been shown to be effective for young people, the mediators and specific change mechanisms of treatment are still unclear.

Aim: As part of the “European Network of Individualized Psychotherapy Treatment of Young People with Mental Disorders” (TREATme), funded by the European Cooperation in Science and Technology (COST), we will conduct a systematic review to summarize the existing knowledge on mediators of treatment outcome and theories of change in psychotherapy for young people with personality disorders. In particular, we will evaluate whether mediators appear to be common or specific to particular age groups, treatment models, or outcome domains (e.g., psychosocial functioning, life quality, and adverse treatment effects).

Method: We will follow the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) statement recommendations. Electronic databases (PubMed and PsycINFO) have been systematically searched for prospective, longitudinal, and case–control designs of psychological treatment studies, which examine mediators published in English. Participants will be young people between 10 and 30years of age who suffer from subclinical personality symptoms or have a personality disorder diagnosis and receive an intervention that aims at preventing, ameliorating, and/or treating psychological problems.

Results: The results will be published in a peer-reviewed journal and at conference presentations and will be shared with relevant stakeholder groups. The data set will be made available to other research groups following recommendations of the open science initiative. Databases with the systematic search will be made openly available following open science initiatives. The review has been registered in PROSPERO (evaluation is pending, registration number ID 248959).

Implications: This review will deliver a comprehensive overview on the empirical basis to contribute to the further development of psychological treatments for young people with personality disorders.

A longitudinal analysis of reflective functioning and its association with psychotherapy outcome in patients with depressive and anxiety disorders

The ability to mentalize has been discussed as potential change mechanism in psychotherapy. Reflective functioning (RF) offers an empirical framework for the assessment of mentalization in therapy sessions. In the present study, we assessed RF longitudinally and examined its association with symptomatic distress, symptom severity of depression and anxiety, and interpersonal problems over the course of treatment. Thirty-seven patients diagnosed with depression or anxiety disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy (CBT) in an outpatient setting. The observer-rated in-session Reflective Functioning Scale (RFS) was applied to transcripts of therapy Sessions 1, 8, 16, and 24. The effects of RF were investigated both within and between patients using hierarchical linear modeling. RF significantly increased over the course of treatment, and this improvement in RF was significantly associated with depressive symptoms. This means that after a session where patients positively deviated from their own average RF during treatment, they reported lower depression severity. In post hoc analyses, we found a significant interaction effect of the within- and between-patient RF effects on interpersonal problems. Patients with overall higher levels of RF and with positive deviations from their own average RF over the course of treatment tended to have less interpersonal problems during psychotherapy. The present study contributes to the preliminary evidence that changes in RF may serve as a common factor in psychotherapy in contrast to being a specific factor in psychodynamic therapies. More longitudinal studies are necessary to gain a better understanding of RF as a change mechanism in psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Entwicklung von Affiliation während der Psychotherapieausbildung

Fragestellung

Die Studie untersuchte die Entwicklung von Affiliation bei psychotherapeutischen Ausbildungskandidat:innen in Bezug auf ihr therapeutisches Handeln, ihre Selbstwahrnehmung und ihre Wahrnehmung von Klient:innen. Zudem wurde der Einfluss von Bindungsrepräsentationen und Selbsterfahrung auf die Affiliation betrachtet.

Material und Methode

In einem naturalistischen Prä-Post-Design bewerteten Ausbildungskandidat:innen unterschiedlicher therapeutischer Orientierungen (n = 126) verschiedene Affiliationsdimensionen in schwierigen Therapiesituationen (Intrex Questionnaire Short Form) über den Abstand von 3 Jahren. Bindungsangst und Bindungsvermeidung wurden zu Beginn (Experiences in Close Relationships, ECR-RD), Länge und Zufriedenheit der Selbsterfahrung am Ende des Erhebungszeitraums erfasst. Die Zusammenhangsanalysen wurden in Mehrebenenmodellen realisiert.

Ergebnisse

Die Affiliation im eigenen therapeutischen Verhalten und in der Wahrnehmung des Klient:innenverhaltens zeigte Steigerungen kleiner Effektgröße, wobei Bindungsvermeidung eine geringere Affiliation im eigenen Verhalten voraussagte. Die selbstbezogene Affiliation nahm mit einer mittleren Effektgröße ab; hierbei war Bindungsangst mit einer niedrigeren Affiliation assoziiert. Die Selbsterfahrungsdauer wies einen negativen Zusammenhang mit der Wahrnehmung des Klient:innenverhaltens auf; dieser Effekt kehrte sich bei hoher Bindungsvermeidung um. Die Zufriedenheit mit Selbsterfahrung hatte keinen Einfluss auf die Affiliationsentwicklung.

Schlussfolgerung

Die interpersonelle und intrapsychische Affiliation von angehenden Psychotherapeut:innen ist z. T. durch Bindungsrepräsentationen geprägt, unterliegt aber Entwicklungsprozessen. Die Abnahme selbstbezogener Affiliation zeigt die Notwendigkeit für kompensatorische und ressourcenstärkende Maßnahmen in der Psychotherapieausbildung.

The competence development of German psychotherapy trainees: A naturalistic, longitudinal and multidimensional outcome study

Objectives:This study investigated the development of German psychotherapy trainees in professional, relational, and personal competence. Methods: The study followed a naturalistic pre-post design over 3 years and included a control group of non-trainee psychologists. The sample consisted of 219 participants, including 64 cognitive-behavioral trainees, 120 psychodynamic trainees and 35 control participants. Outcomes were knowledge (multiple choice exam), case-formulation competence (Case Formulation Content Coding Method), healing and stressful involvement (Therapist Work Involvement Scales), attributional complexity (Attributional Complexity Scale), introject affiliation, and affiliation in patient treatments (Intrex questionnaire). Multilevel Modeling was used to investigate change over time and group by time interactions. Comparisons to the control group were limited to knowledge, case-formulation competence, and attributional complexity. Results: Trainees improved in knowledge, case-formulation competence, healing involvement, and affiliation in treatments with small to medium effects. There was no change in stressful involvement, attributional complexity or introject affiliation. According to reliable change indices, the majority of trainees did not change reliably. Over time, trainees outperformed the control group only in case-formulation competence. There were several main and group by time effects regarding trainee orientation. Conclusions: Results imply benefits of training on professional and relational competence but only limited effects on personal competence.

Mediators in Psychological Treatments for Anxiety and Depression in Adolescents and Young People: A Protocol of a Systematic Review

Introduction

Anxiety and depressive disorders are a significant problem that starts in childhood or adolescence and should be addressed early to avoid chronic mental conditions. There is strong evidence to demonstrate that psychological treatments are effective for these disorders, however, little is known on mediators and mechanisms of change of psychological treatment in adolescents and young adults. Understanding the pathways through which psychological treatments operate will facilitate more effective treatments.

Aim

We aim to conduct a systematic review, exploring the available evidence on mediators of psychological treatments for anxiety and depression in adolescents and young adults.

Methods

A systematic search has been performed on PubMed and PsycINFO databases to identify studies from inception to 23rd February 2020. Eligible studies include randomized controlled trials and trials (quasi-experimental) designs that have enrolled adolescents and young adults presenting with depression and/or anxiety and that have examined mediators of psychological treatments. A group of 20 reviewers from the COST-Action TREATme (CA16102) divided into 10 pairs independently screen studies for inclusion, extract information from the included studies, and assess the methodological quality of the included studies and the requirements for mediators. The methodological quality will be assessed by The Mixed Methods Appraisal Tool. Extracted data from the included studies will be collected and presented using a narrative approach.

Discussion

This systematic review will summarize and provide a comprehensive overview of the current evidence on mediators of psychological treatments for anxiety and depression for adolescents and young adults. Results will allow the identification of strategies to optimize intervention to enhance clinical outcomes.

Ethics and dissemination

Ethics approval is not required. Findings from this systematic review will be published in a peer-reviewed journal and disseminated at conferences and meetings. PROSPERO registration number: CRD42021234641.

Mentalization-based treatment for adolescents with conduct disorder (MBT-CD): protocol of a feasibility and pilot study

BACKGROUND

Conduct disorder (CD) is a complex mental disorder characterized by severe rule-breaking and aggressive behavior. While studies have shown that several therapeutic interventions are effective in treating CD symptoms, researchers call for treatments based on etiological knowledge and potential patho-mechanisms. Mentalization-based treatment (MBT) may represent such a treatment approach: Studies have shown that individuals with CD show mentalizing deficits and that mentalizing might represent a protective factor against the development of the disorder. As MBT focuses on the understanding of social behavior in terms of mental states, fostering mentalizing might help CD individuals to (re)gain an adaptive way of coping with negative emotions especially in social interactions and thus reduce aggressive behavior. For this purpose, MBT was adapted for adolescents with CD (MBT-CD). This is a protocol of a feasibility and pilot study to inform the planning of a prospective RCT. The primary aim is to estimate the feasibility of an RCT based on the acceptability of the intervention and the scientific assessments by CD individuals and their families indicated by quantitative and qualitative data, as well as based on necessary organizational resources to conduct an RCT. The secondary aim is to investigate the course of symptom severity and mentalizing skills.

METHODS

The bi-center study is carried out in two outpatient settings associated with university hospitals (Heidelberg and Mainz) in Germany. Adolescents aged between 11 and 18 years with a CD or oppositional defiant disorder (ODD) diagnosis are included. Participants receive MBT-CD for 6 to 12 months. The primary outcome of the feasibility study (e.g., recruitment and adherence rates) will be descriptively analyzed. Multilevel modeling will be used to investigate secondary outcome data.

DISCUSSION

Fostering the capacity to mentalize social interactions triggering non-mentalized, aggressive behavior might help CD individuals to behave more adaptively. The feasibility trial is essential for gathering information on how to properly conduct MBT-CD including appropriate scientific assessments in this patient group, in order to subsequently investigate the effectiveness of MBT-CD in an RCT.

TRIAL REGISTRATION

ClinicalTrials.gov , NCT02988453 . November 30, 2016 SOURCES OF MONETARY SUPPORT: Dietmar Hopp Stiftung, Heidehof Stiftung RECRUITMENT STATUS: Recruitment complete and intervention complete, follow-up assessments ongoing (Heidelberg). Recruitment and assessments ongoing (Mainz). PRIMARY SPONSOR, PRINCIPAL INVESTIGATOR, AND LEAD INVESTIGATOR IN HEIDELBERG: Svenja Taubner is responsible for the design and conduct of MBT-CD intervention and feasibility and pilot study, preparation of protocol and revisions, and publication of study results.

SECONDARY SPONSOR AND LEAD INVESTIGATOR IN MAINZ

Esther Sobanski is responsible for the recruitment and data collection in the collaborating center Mainz RECRUITMENT COUNTRY: Germany HEALTH CONDITION STUDIED: Conduct disorder, oppositional defiant disorder INTERVENTION: Mentalization-based treatment for conduct disorder (MBT-CD): MBT-CD is an adaptation of MBT for Borderline Personality Disorder. This manualized psychodynamic psychotherapy focuses on increasing mentalizing, i.e., the ability to understand behavior in terms of mental states, in patients. MBT-CD includes weekly individual sessions with the patient and monthly family sessions.

KEY INCLUSION AND EXCLUSION CRITERIA

Included are adolescent individuals with a diagnosis of conduct disorder or oppositional defiant disorder aged between 11 and 18 years.

STUDY TYPE

Feasibility and pilot study (single-group) DATE OF FIRST ENROLLMENT: 19.01.2017 STUDY STATUS: The trial is currently in the follow-up assessment phase in Heidelberg and in the recruitment and treatment phase in Mainz.

PRIMARY OUTCOMES

Acceptability of MBT-CD intervention (as indicated by recruitment rates, completion rates, drop-out rates, treatment duration, oral evaluation), acceptability of scientific assessments (as indicated by adherence, missing data, oral evaluation), and necessary organizational resources (scientific personnel, recruitment networks, MBT-CD training and supervision) to estimate feasibility of an RCT SECONDARY OUTCOMES: Adolescents' symptom severity and mentalizing ability PROTOCOL VERSION: 20.08.2020, version 1.0.

Stabil in und nach der Krise

Die aktuelle COVID-19 Pandemie stellt eine große Herausforderung dar für die psychische Gesundheit der Allgemeinbevölkerung und speziell der Mitarbeiter*innen des Gesundheitssystems. In diesem Beitrag wird ein Überblick sowohl zu den allgemeinen psychischen Belastungsfaktoren wie zu den speziellen Herausforderungen für Gesundheitsfachkräfte im Rahmen der COVID-19 Pandemie gegeben. Daran anschließend werden psychosoziale und organisationale Handlungsempfehlungen für das Pflegemanagement im Rahmen der COVID-19 Pandemie vermittelt mit dem Ziel, psychische Belastungen der Mitarbeiter*innen des Gesundheitswesens in der aktuellen Hochbelastungsphase zu reduzieren und die psychische Nachsorge vorzubereiten.

The Efficacy of Brief Parent-Infant Psychotherapy for Treating Early Regulatory Disorders: A Randomized Controlled Trial

OBJECTIVE

Early regulatory disorders (ERD) place considerable strain on the parent-infant relationship and are associated with high parental distress. Brief (4-session) psychodynamic-based focused parent-infant psychotherapy (fPIP) treats ERD by strengthening the quality of the parent-infant relationship. This randomized controlled trial investigates the efficacy of fPIP for treating ERD compared to standard pediatric care (treatment as usual [TAU]).

METHOD

Participants were 154 mothers and infants from 4 to 15 months who met criteria for persistent excessive crying, sleeping disorders, feeding disorders, or regulation disorders of sensory processing and were randomly assigned to fPIP (n = 81) or TAU (n = 73). Assessments took place at baseline and at the end of treatment after 12 weeks. Primary outcomes were the infants' regulatory symptoms and remission rate. Secondary outcomes were parents' psychological distress, depression, parenting stress, maternal self-efficacy, parental reflective functioning, and observer-rated emotional availability.

RESULTS

fPIP was superior to TAU in reducing infants' overall symptoms (p = .004, η² = 0.05, CI = 0.01-0.12), night-waking disorders (p = .030, odds ratio = 3.12, CI = 1.21-9.22), and mothers' psychological distress (p = .000, η² = 0.08, CI = 0.03-0.16) and depression (p = .002, η² = 0.06, CI = 0.02-0.13). There was a trend suggesting that fPIP led to increased maternal self-efficacy and parental reflective functioning.

CONCLUSION

Results underscore the efficacy of brief fPIP in significantly reducing symptoms in infants with ERD and their mothers. Generalizability is restricted to low psychosocial risk samples with highly distressed mothers and comorbid ERD with a predominance of night-waking disorders.

CLINICAL TRIAL REGISTRATION INFORMATION

The Efficacy of a Brief Parent-Infant Psychotherapy for the Treatment of Early Regulatory Disorders: A Randomized Controlled Trial; https://www.drks.de/drks_web/; DRKS00005739.

Mediators and theories of change in psychotherapy with adolescents: a systematic review protocol

INTRODUCTION

Approximately 75% of mental disorders emerge before the age of 25 years but less than half receive appropriate treatment. Little is known about the mechanisms underlying the therapeutic change of adolescents in psychotherapy. The 'European Network of Individualised Psychotherapy Treatment of Young People with Mental Disorders', funded by the European Cooperation in Science and Technology, will conduct the first systematic review to summarise the existing knowledge on mediators and theories of change in psychotherapy for adolescents.

METHOD

A systematic review will be conducted, conforming to the reporting guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses statement recommendations. Electronic databases (PubMed and PsycINFO) have been systematically searched on 23 February 2020, for prospective, longitudinal and case-control designs which examine mediators of change. Participants will be adolescents between 10 and 19 years of age who suffer from a mental disorder or psychological difficulties and receive an intervention that aims at preventing, ameliorating and/or treating psychological problems.

ETHICS AND DISSEMINATION

Ethical approval is not required for this systematic review as no primary data will be collected. The results will be published in a peer-reviewed journals and at conference presentations and will be shared with stakeholder groups. The whole data set will be offered to other research groups following recommendations of the open science initiative. Databases with the systematic search will be made openly available following open science initiatives.

PROSPERO REGISTRATION NUMBER

CRD42020177535.

Identity Development and Maladaptive Personality Traits in Young Refugees and First- and Second-Generation Migrants

Refugees are often exposed to a variety of stressors and traumatic events, posing a significant risk for the development of mental disorders. Young refugees may be particularly at risk because adverse life events affect identity formation, a developmental task that is typically expected in adolescence and emerging adulthood. Trauma and cultural changes may alter identity development, potentially leading to identity diffusion, a core concept of personality disorders. However, previous research on personality pathology among refugees is scarce. In this study, we examine identity development and maladaptive personality traits in young refugees and migrants. Refugees from 22 countries of origin were recruited in a German reception center (n = 120) and a group of adults with a migration background in first- or second generation was obtained via web-based recruitment (n = 281). Identity development was measured using the Assessment of Identity Development in Adolescence - Short Form. Maladaptive personality traits were assessed with the Personality Inventory for DSM-5-Brief Form. Group differences between refugees and migrants regarding identity development and trait expression were investigated using t-tests. The relationship between the two measures and their corresponding subscales was examined by means of correlation analyses. Refugees reported significantly higher levels of identity diffusion, negative affectivity, detachment, antagonism, and disinhibition compared to migrants. No significant differences were found for psychoticism. Correlation analyses revealed low to moderate positive associations between identity diffusion and maladaptive trait expression. Possible implications for early phase of resettlement, preventive psychiatric care and further research questions are discussed.

Epistemic Trust and the Emergence of Conduct Problems: Aggression in the Service of Communication

Fonagy and colleagues have recently proposed that deficits in the capacity for epistemic trust (i. e., the expectation that interpersonal communication is relevant to the addressee) are fundamental to psychopathology. In this paper, we consider the implications of this hypothesis for understanding the role of aggression in conduct disorder and conduct problems more generally. Our main proposal is to view conduct problems not only as reflecting dysregulation, but as an adaptation that allows communication with others who are (or are perceived to be) unreliable. Our formulation hinges on two propositions. The first one is to view aggression as a modality of communication adapted to scenarios in which the communicator expects the audience to have low epistemic trust in the communicator. The second idea is to conceptualize the failed "unlearning of aggression" as reflecting a lack of interest in maintaining one's reputation as a communicator, which in turn stems from a lack of epistemic trust in other communicators. In this paper, we discuss these ideas and examine how they may account for the developmental pathways that lead young people to develop conduct problems.

Maternal Parenting Stress in the Face of Early Regulatory Disorders in Infancy: A Machine Learning Approach to Identify What Matters Most

Objective: Early regulatory disorders (ERD) in infancy are typically associated with high parenting stress (PS). Theoretical and empirical literature suggests a wide range of factors that may contribute to PS related to ERD. The aim of this study was to identify key predictors of maternal PS within a large predictor data set in a sample of N = 135 mothers of infants diagnosed with ERD. Methods: We used machine learning to identify relevant predictors. Maternal PS was assessed with the Parenting Stress Index. The multivariate dataset assessed cross-sectionally consisted of 464 self-reported and clinically rated variables covering mother-reported psychological distress, maternal self-efficacy, parental reflective functioning, socio-demographics, each parent's history of illness, recent significant life events, former miscarriage/abortion, pregnancy, obstetric history, infants' medical history, development, and social environment. Variables were drawn from behavioral diaries on regulatory symptoms and parental co-regulative behavior as well as a clinical interview which was utilized to diagnose ERD and to assess clinically rated regulatory symptoms, quality of parent-infant relationship, organic/biological and psychosocial risks, and social-emotional functioning. Results: The final prediction model identified 11 important variables summing up to the areas maternal self-efficacy, psychological distress (particularly depression and anger-hostility), infant regulatory symptoms (particularly duration of fussing/crying), and age-appropriate physical development. The RMSE (i.e., prediction accuracy) of the final model applied to the test set was 21.72 (R ² = 0.58). Conclusions: This study suggests that among behavioral, environmental, developmental, parent-infant relationship, and mental health variables, a mother's higher self-efficacy, psychological distress symptoms particularly depression and anger symptoms, symptoms in the child particularly fussing/crying symptoms, and age-inappropriate physical development are associated with higher maternal PS. With these factors identified, clinicians may more efficiently assess a mother's PS related to ERD in a low-risk help-seeking sample.

Differences in attachment dimensions and reflective functioning between traumatized juvenile offenders and maltreated non-delinquent adolescents from care services

BACKGROUND

Adverse childhood experiences, especially maltreatment, are regarded as significant risk factors for the development of antisocial behavior in adolescence. However, possible correlates are still to be investigated after considering the history of criminal records and the experience of institutionalization.

OBJECTIVE

In this study, differences in attachment anxiety and avoidance, and reflective functioning (RF) between traumatized incarcerated juvenile offenders and non-delinquent adolescents institutionalized in child services because of domestic violence were examined.

PARTICIPANTS, SETTING AND METHOD

Forty-two juvenile offenders (N_female = 19) and 43 inmates of institutions for adolescents without parental care (N_female = 20) with the history of trauma filled in the childhood trauma and attachment dimensions questionnaires, and were scored on the Reflective Functioning Scale. Groups were matched on age and education.

RESULTS

Results indicate that both groups reported equally high levels of attachment anxiety and avoidance. Male juvenile offenders had lower scores on reflective functioning than both female convicted minors (B = 1.06; Odds Ratio = 2.88; Nagelkerkes R² = 45) and non-delinquent adolescents of both genders (B = -.65; Odds Ratio = .52; Nagelkerkes R² = 42). In comparison to non-convicted males, male offenders also had higher scores on the control scale of idealization (B = .35; Odds Ratio = 1.42; Nagelkerkes R² = 42). No differences between females with and without a history of crimes were found.

CONCLUSIONS

Results indicate a need for building RF in both traumatized samples, especially in male delinquents, and encourage further research in females.

Mediators in psychological and psychoeducational interventions for the prevention of depression and anxiety. A systematic review

Although efforts have been undertaken to determine how psychological interventions exert their effects, research on mediators and mechanisms of change remains limited, especially in the field of prevention. We aimed to assess available evidence on mediators of psychological and psychoeducational interventions for the prevention of depression and anxiety in varied populations. A systematic review using PubMed, PsycINFO, Web of Science, Embase, OpenGrey, and the Cochrane Central Register of Controlled Trials was performed. Two independent reviewers assessed the eligibility criteria of all articles, extracted data, determined the risk of bias in randomized controlled trials, and the requirements for mediators. The outcomes were mediators of the incidence of depression or anxiety and/or the reduction of symptoms of depression or anxiety. We identified 28 nested mediator studies within randomized controlled trials involving 7442 participants. Potential cognitive, behavioral, emotional and interpersonal mediators were evaluated in different psychological and psychoeducational interventions to prevent depression and anxiety. The effects were mediated mainly by cognitive variables, which were the most commonly assessed factors. For depression, the mediator with the strongest empirical support was negative thinking in adults. Cognitive change is an important mediator in preventive psychological and psychoeducational interventions for both anxiety and depression. REGISTRATION DETAILS: Registration number (PROSPERO): CRD42018092393.

Euthanasia and assisted suicide in patients with personality disorders: a review of current practice and challenges

BACKGROUND

Over the last two decades an increasing number of countries have legalized euthanasia and physician-assisted suicide (EAS) leading to considerable debate over the inherent ethical dilemmas. Increasing numbers of people with personality disorders, faced with unbearable suffering, have requested and received assistance in terminating their lives. EAS in people with personality disorders has, however, received very sparse attention from clinicians and researchers. In this paper, we examine the literature on the practice and prevalence of EAS in people with personality disorders to date and discuss the associated challenges for research and practice.

METHODS

Narrative review of the literature combined with the authors' collective experience and knowledge of personality disorders.

RESULTS

In six of the eight countries where EAS is currently legal, mental disorders are accepted as disorders for which EAS may be granted. In four of these countries, EAS in minors with mental disorders is also accepted. Our literature search resulted in 9 papers on the subject of EAS in people with personality disorders. These studies suggest that most clinicians who grant EAS have indeed perceived their patients' suffering as chronic, unbearable and untreatable without prospect of improvement. The majority of patients with personality disorders had tried some form of psychotherapy, but very few had received any of the relevant evidence-based treatments. The decision to grant EAS based on a perception of the patient's illness as being untreatable with no prospect of improvement, could, thus, in many cases fail to meet the due care criteria listed in EAS laws. People with personality disorders more often wish for death for extended periods of time than people without these disorders. However, there is ample empirical data to show that suicidal tendencies and behaviour can be treated and that they fluctuate rapidly over time.

CONCLUSIONS

In light of our findings, we believe that the current legislation and practice of EAS for people with personality disorders is based on an inadequate understanding of underlying psychopathology and a lack of awareness about the contemporary treatment literature. Moreover, we assert that this practice neglects the individual's potential for having a life worth living.