Jon G. Allen

Handbook of mentalization-based treatment

About the Editors. List of Contributors. Foreword by Susan W. Coates. Preface by Jon G. Allen and Peter Fonagy. Part I: CONCEPTUAL AND CLINICAL FOUNDATIONS. 1 Mentalizing in Practice (Jon G. Allen). 2 Mentalizing from a Psychoanalytic Perspective: Whats New? (Jeremy Holmes). Part II: DEVELOPMENTAL PSYCHOPATHOLOGY. 3 The Mentalization-Focused Approach to Social Development (Peter Fonagy). 4 Mentalizing Problems in Childhood Disorders (Carla Sharp). 5 A Neurobiological Perspective on Mentalizing and Internal Object Relations in Traumatized Patients with Borderline Personality Disorder (Glen O. Gabbard, Lisa A. Miller and Melissa Martinez). Part III: INCORPORATING MENTALIZING IN ESTABLISHED TREATMENTS. 6 Integrating Mentalization-Based Treatment and Traditional Psychotherapy to Cultivate Common Ground and Promote Agency (Richard L. Munich). 7 Cognitive Behavioral Therapy Promotes Mentalizing (Throstur Bjorgvinsson and John Hart). 8 Enhancing Mentalizing Capacity through Dialectical Behavior Therapy Skills Training and Positive Psychology (Lisa Lewis). Part IV: MENTALIZATION-BASED THERAPY. 9 Mentalizing and Borderline Personality Disorder (Anthony Bateman and Peter Fonagy). 10 Short-Term Mentalization and Relational Therapy (SMART): An Integrative Family Therapy for Children and Adolescents (Pasco Fearon, Mary Target, Peter Fonagy, Laurel L. Williams, Jacqueline McGregor, John Sargent and Efrain Bleiberg). 11 Training Psychiatry Residents in Mentalization-Based Therapy (Laurel L.Williams, Peter Fonagy, Mary Target, Pasco Fearon, John Sargent, Efrain Bleiberg and Jacqueline McGregor). 12. Treating Professionals in Crisis: A Mentalization-Based Specialized Inpatient Program (Efrain Bleiberg). 13. Enhancing Mentalizing through Psycho-Education (G. Tobias G. Haslam-Hopwood, Jon G. Allen, April Stein and Efrain Bleiberg). Part V: PREVENTION. 14. Minding the Baby: A Mentalization-Based Parenting Program (Lois S. Sadler, Arietta Slade and Linda C. Mayes). 15. Transforming Violent Social Systems into Non-Violent Mentalizing Systems: An Experiment in Schools (Stuart W. Twemlow and Peter Fonagy). 16. Does Mentalizing Promote Resilience? (Helen Stein). Epilogue (Robert Michels). Index.

Adult attachment: What are the underlying dimensions?

Using a community sample of 115 young adults, this study applied a range of statistical techniques to five measures of adult attachment to gain a better understanding of what they assess. First, we determined comparability of measures, using both categorical and dimensional approaches to model the association. Agreement among classifications was modest. Next, we examined the relation of attachment classifications and attachment measure subscale scores to criterion variables (i.e. dyadic adjustment, interpersonal sensitivity and severity of psychiatric symptoms). Classification predicted severity of psychological symptoms better than it predicted other measures of adjustment. Finally, using a principal components analysis, we mapped the relationship among underlying constructs, the subscales of the five measures and three criterion measures of psychological adjustment. We discuss our findings from the perspective of underlying constructs of attachment insecurity and strategy for coping with insecurity in relationships, noting implications for further research.

Dissociative detachment relates to psychotic symptoms and personality decompensation.

Previous studies have addressed the prominence of psychotic symptoms in conjunction with multiple personality disorder (now dissociative identity disorder). The present study examines the relation between psychotic symptoms and a more pervasive form of dissociative disturbance, namely dissociative detachment. Two hundred sixty-six women in inpatient treatment for severe trauma-related disorders completed the Dissociative Experiences Scale (DES), and 102 of these patients also completed the Millon Clinical Multiaxial Inventory (MCMI-III). A factor analysis of the DES yielded two dimensions of dissociative detachment: detachment from ones own actions and detachment from the self and the environment. Each of these DES dimensions relates strongly to the thought disorder and schizotypal personality disorder scales of the MCMI-III. We propose that severe dissociative detachment, by virtue of loosening the moorings in inner and outer reality, is conducive to psychotic symptoms and personality decompensation.

Dissociation and vulnerability to psychotic experience. The Dissociative Experiences Scale and the MMPI-2.

Prior research on the MMPI has cautioned against misdiagnosing schizophrenia in patients with dissociative identity disorder. The present study examined the full spectrum of the dissociative experience in relation to MMPI-2 profiles. Ninety-eight women in treatment for trauma-related disorders completed the Dissociative Experiences Scale and the MMPI-2 in routine inpatient diagnostic evaluations. Consistent with prior research, severe dissociation was associated with high elevations on MMPI-2 scales typically associated with psychotic symptoms. Contrary to hypotheses, the ostensibly most benign form of dissociation, absorption and imaginative involvement, was somewhat more strongly related to MMPI-2 scores than the more pathognomonic forms of dissociation, depersonalization and amnesia. Although it should not be misdiagnosed, severe impairment on the MMPI in conjunction with dissociation should be taken seriously as suggesting vulnerability to psychotic experience. The dissociative retreat from the stressors of outer reality opens the door to the inner world of traumatic images and affects, along with compromised reality testing and disorganized thinking.

Transference interpretation in the psychotherapy of borderline patients : a high-risk, high-gain phenomenon

&NA; The effectiveness of transference interpretation in the psychodynamic psychotherapy of patients with borderline personality disorder has been highly controversial. Both highly expressive approaches that stress the value of transference interpretation and supportive strategies that eschew transference work have been advocated in the literature. We review this literature and identify three emerging trends in thought: (1) Primarily interpretive approaches should be reserved for patients with greater levels of ego strength. (2) Whichever technique is used, a strong therapeutic alliance is the foundation of treatment. (3) Expressive and supportive techniques should not be juxtaposed as polarized opposites; supportive interventions often pave the way for transference interpretation. Our psychotherapy process study revealed that transference interpretations tended to have greater impact‐both positive and negative‐than other interventions made with patients with borderline personality disorder. We conclude that such factors as neuropsychologically based cognitive dysfunction, a history of early trauma, patterns of object relations involving interpersonal distance, masochistic tendencies, and anaclltic rather than Introjective psychopathology are among the patient characteristics that influence the impact of transference interpretation on the therapeutic alliance. Bias toward expressive technique and countertransference issues appear to be relevant to the therapists difficulty in shifting to a more supportive approach when indicated.

Construct validity and factor structure of the difficulties in Emotion Regulation Scale among adults with severe mental illness

BACKGROUND The Difficulties in Emotion Regulation Scale (DERS: Gratz and Roemer, 2004) is a measure of emotion-regulation capacities with good construct validity, test-retest reliability and internal consistency. Factor analytic studies have produced mixed results, with the majority of studies supporting the original 6-factor model while several studies advance alternative 5-factor models, each of which raises questions about the psychometric validity of the Lack of Emotional Awareness factor. A limitation of prior psychometric studies on the DERS is the reliance on healthy subjects with minimal impairment in emotion regulation. The current study assesses the construct validity and latent factor structure of the DERS in a large sample of adult psychiatric inpatients with serious mental illness (SMI). METHODS Inpatients with SMI (N = 592) completed the DERS, Acceptance and Action Questionnaire (AAQ-2), Patient Health Questionnaire (PHQ-SADS), and research diagnostic interviews (SCID I/II) at admission. RESULTS DERS total scores were correlated with AAQ-2 (r = .70), PHQ-Depression (r = .45), PHQ-Anxiety (r = .44) and moderately correlated with PHQ-Somatization (r = .28). Confirmatory factor analysis indicated that five and six-factor model produced equivalent fit indices. All factors demonstrated positive correlations with the exception of difficulty engaging in goal-directed behavior and lack of emotional awareness. CONCLUSIONS The DERS is a strong measure with excellent internal consistency and good construct validity. Caution is warranted in discarding the six-factor model given the equivalence with the five-factor model, particularly in light of the body of clinical research evidence utilizing the full scale.

Exposure to interpersonal trauma, attachment insecurity, and depression severity

BACKGROUND Exposure to traumatic events is a nonspecific risk factor for psychiatric symptoms including depression. The trauma-depression link finds support in numerous studies; however, explanatory mechanisms linking past trauma to current depressive symptoms are poorly understood. This study examines the role that attachment insecurity plays in mediating the relationship between prior exposure to trauma and current expression of depression severity. METHODS Past trauma and attachment anxiety and avoidance were assessed at baseline in a large cohort (N=705) of adults admitted to a specialized adult psychiatric hospital with typical lengths of stay ranging from 6 to 8 weeks. Depression severity was assessed at day 14 of treatment using the Beck Depression Inventory-II. RESULTS Interpersonal trauma (e.g., assaults, abuse) was correlated with depression severity, whereas exposure to impersonal trauma (e.g., natural disasters, accidents) was not. Adult attachment partially mediated the relationship between past interpersonal trauma and depression severity at day 14 among psychiatric inpatients. LIMITATIONS Measure of trauma exposure did not systematically differentiate the age of exposure or relationship to the perpetrator. Individuals scoring high on the self-report attachment measure may be prone to over-report interpersonal traumas. CONCLUSIONS Treatment of depression in traumatized patients should include an assessment of attachment insecurity and may be fruitful target for intervention.

Therapeutic alliance and long-term hospital treatment outcome

the quality of the therapeutic alliance is prominent in the thinking of all members of the [multidisciplinary treatment] team, it would seem important that this variable find a more consistent place in clinical research” (p. 420). Yet, there has been no systematic assessment of the role of the alliance in hospital treatment comparable to the work in the field of psychotherapy. The importance of the alliance was reaffirmed in a pilot study in which staff members described factors contributing positively and negatively to the treatment outcome for all patients discharged over the course of one year. Numerous characteristics reflecting the level of alliance emerged. On the positive side were reflectiveness, insightfulness, willingness to examine behavior, awareness of illness, willingness to work with staff, agreeing on treatment plans, wishing to work in treatment, determination to overcome problems, ability to set goals, and so forth; on the negative side were denial of illness, resisting exploration, oppositionalism. refusing to follow the treatment structure, acting out in such a way as to disrupt treatment, lack of desire to change, and inability to set realistic goals or to follow through with goals. Issues related to patient “likability” were mentioned even more frequently: indeed, some staff members speculated that patients’ likability might be the most significant predictor of the success of the treatment process inasmuch as the more likable patients might be expected to form more positive treatment relationships. On the positive side, this dimension included friendliness, charm, appeal, attractiveness, and sense of humor, along with references to patients’ capacities to form attachments and to evoke the interest and concern of staff; on the negative side were hostility, contempt, repugnant behavior, aloofness, and so forth. Like the alliance, likability has been found to play a positive role in the outcome of psychotherapy.‘-” Any attempt to research the alliance in relation to treatment outcome must come to terms with the wide variation in authors’ conceptualizations and assessment methods. Most researchers incorporate a broad range of positive and negative experiences and contributions to the alliance on the part of the patient and the

Anhedonia predicts suicidal ideation in a large psychiatric inpatient sample.

This study examined the relationship among symptoms of anhedonia and suicidal ideation at baseline, at termination, and over time in 1529 adult psychiatric inpatients. Anhedonia was associated with suicidality cross-sectionally at baseline and at termination. In addition, change in anhedonia from baseline to termination predicted change in suicidality from baseline to termination, as well as level of suicidality at termination; moreover, anhedonia remained a robust predictor of suicidal ideation independent of cognitive/affective symptoms of depression. Symptom-level analyses also revealed that, even after accounting for the physical aspect of anhedonia (e.g., loss of energy), loss of interest and loss of pleasure were independently associated with higher levels of suicidal ideation at baseline, over time, and at discharge. Loss of interest was most highly predictive of suicidal ideation, providing support for recent differential conceptualizations of anhedonia. Taken together, these findings indicate that the manner in which anhedonia is conceptualized is important in predicting suicidal ideation, and that anhedonia symptoms warrant particular clinical attention in the treatment of suicidal patients.

Complexities in complex posttraumatic stress disorder in inpatient women: evidence from cluster analysis of MCMI-III Personality Disorder Scales.

Hermans (1992a) clinical formulation of complex posttraumatic stress disorder (PTSD) captures the extensive diagnostic comorbidity seen in patients with a history of repeated interpersonal trauma and severe psychiatric disorders. Yet the sheer breadth of symptoms and personality disturbance encompassed by complex PTSD limits its descriptive usefulness. This study employed cluster analysis of the MCMI-III (Millon, 1994) personality disorder scales to determine whether there is meaningful heterogeneity within a group of 227 severely traumatized women who were treated in a specialized inpatient program. The analysis distinguishes 5 clinically meaningful clusters, which we label alienated, withdrawn, aggressive, suffering, and adaptive. The study examined differences among these 5 personality disorder clusters on the MCMI-III clinical syndrome scales, as well as on the Brief Symptom Inventory (Derogatis, 1993), Dissociative Experiences Scale (E. M. Bernstein & Putnam, 1986), Adult Attachment Scale (Collins & Read, 1990), and Childhood Trauma Questionnaire (D.P. Bernstein, 1995). We present a classification-tree method for determining the cluster membership of new cases and discuss the implications of the findings for diagnostic assessment, treatment, and research.