Karin Ensink

Intergenerational Transmission of Attachment in Abused and Neglected Mothers: The Role of Trauma-Specific Reflective Functioning

There are still important gaps in our knowledge regarding the intergenerational transmission of attachment from mother to child, especially in mothers with childhood histories of abuse and neglect (CA&N). This study examined the contributions of reflective function concerning general attachment relationships, and specifically concerning trauma, as well as those of maternal attachment states of mind to the prediction of infant attachment disorganization in a sample of mothers with CA&N and their infants, using a 20-month follow-up design. Attachment and reflective functioning were assessed during pregnancy with the Adult Attachment Interview. Infant attachment was evaluated with the Strange Situation Procedure. The majority (83%) of infants of abused and neglected mothers were classified as insecure, and a significant proportion (44%) manifested attachment disorganization. There was a strong concordance between mother and child attachment, indicative of intergenerational transmission of attachment in parents with CA&N and their infants. Both unresolved trauma and trauma-specific reflective function made significant contributions to explaining variance in infant attachment disorganization. The findings of this study highlight the importance of trauma-specific mentalization in the intergenerational transmission of attachment by mothers with a history of childhood maltreatment, and provide new evidence of the importance of the absence of mentalization regarding trauma for infant attachment.

The measurement of reflective function in adolescents with and without borderline traits

Reflective function refers to the capacity to reflect on the mind of self and others in the context of the attachment relationship. Reflective function (and its conceptual neighbor, mentalizing) has been shown to be an important correlate of a variety of disorders, including borderline personality disorder (BPD). The current study examined the construct validity of the Reflective Function Questionnaire for Youths (RFQY) in an inpatient sample of adolescents. Adequate internal consistency was established for the RFQY. Significant positive associations with an interview-based measure of reflective function and an experimental-based assessment of mentalization were found for the RFQY. Strong negative relations with BPD features were found and adolescent patients who scored above clinical cut-off for BPD symptoms demonstrated significantly poorer reflective function compared to patients without the disorder. These findings provide preliminary support for the notion that reflective function can be validly and reliably assessed in adolescent populations.

Another step closer to measuring the ghosts in the nursery: preliminary validation of the Trauma Reflective Functioning Scale

The aim of this study was to examine preliminary evidence of the validity of the Trauma Reflective Functioning Scale and to investigate reflective functioning (RF) and attachment in pregnant women with histories of trauma, with a particular focus on the capacity to mentalize regarding trauma and its implications for adaptation to pregnancy and couple functioning. The Adult Attachment Interview was used to assess attachment, unresolved trauma and mentalization (measured as RF) regarding relationships with attachment figures (RF-G) and trauma (RF-T) in 100 pregnant women with histories of abuse and neglect. The majority (63%) of women had insecure attachment states of mind and approximately half were unresolved regarding trauma. Furthermore, the majority of women manifested deficits specific to RF-T. Their RF-T was significantly lower than their RF-G; the findings indicate that women with histories of childhood abuse and neglect do not manifest a generic inhibition of reflectiveness, but a collapse of mentalization specific to trauma. Low RF-T, indicative of difficulty in considering traumatic experiences in mental state terms, was associated with difficulty in investment in the pregnancy and lack of positive feelings about the baby and motherhood. In addition, low RF-T was also associated with difficulties in intimate relationships. Results of a regression analysis with RF indicated that RF-T was the best predictor of investment in pregnancy and couple functioning. In sum, the study provides preliminary evidence that RF-T can be reliably measured and is a valid construct that has potential usefulness for research and clinical practice. It highlights the importance of mentalization specifically about trauma and suggests that it is not the experience of trauma per se, but the absence of mentalization regarding trauma that is associated with difficulties in close relationships and in making the transition to parenthood.

The Development of Mentalisation in Children From a Theory of Mind Perspective

For psychoanalysts, a key developmental question is how childrens mentalisation capacities develop, that is, how they come to understand the feelings and intentions of others, as well as themselves, and how that understanding is integrated over the course of development into their feelings for and expectations of others. Broadly stated, this question has been the subject of productive lines of inquiry among cognitive and development psychologists. During the past 15 years, investigators from these disciplines focusing on the development of theory of mind have provided us with startling evidence of the abilities of very young children to understand their own behavior, as well as that of others, based on beliefs and desires. Furthermore, they have also presented fascinating observations and experiments suggesting that from early infancy we attribute intentionality to people. The term theory of mind has come to designate a specific domain of inquiry and research for philosophers, cognitive developmentalists, and primatologists, with the broad goal of understanding the ability, which may or not be exclusively human, to predict and explain the actions of self and others based on their knowledge, beliefs, and desires. Our aim in this review is to provide a summary of this body of work.

The impact of mentalization training on the reflective function of novice therapists: A randomized controlled trial

Abstract This study examined whether training can increase the reflective function (RF) of novice therapists about patients with Borderline Personality Disorder (BPD). A total of 48 students in clinical psychology were randomly assigned to mentalization training or didactic training. Their RF regarding patients was assessed with the Therapist Mental Activity Scale (TMAS: Normandin, Ensink, & Maheux, 2012). The RF of trainees assigned to the mentalization training improved significantly, while participants who received traditional didactic training actually became significantly less reflective. These findings show that brief mentalization training can help beginner therapists develop their mentalization capacities with challenging patients.

Maternal and child reflective functioning in the context of child sexual abuse: pathways to depression and externalising difficulties

Background Sexual abuse is a well-recognised risk factor for child psychopathology. Little is known regarding whether child and maternal mentalization can be considered a potential resource or protective factor in this context, respectively, mediating or moderating the relationship between sexual abuse and psychopathology. Objective The aims of this study were (1) to explore the relationships between child and maternal mentalizing, measured as reflective functioning (RF), and child depressive symptoms and externalising difficulties; and (2) to examine whether child mentalizing mediates the relationship between child sexual abuse (CSA) and psychopathology. Method A total of 168 children aged 7–12 years and their mothers participated in the study. The sample included 74 dyads where children had experienced sexual abuse. The Child Attachment Interview was rated by using the Child Reflective Functioning Scale to assess childrens mentalization, and the Child Depression Inventory was used to assess depressive symptoms. Mothers completed the Parent Development Interview to assess maternal RF and the Child Behavior Checklist to assess their childs externalising difficulties. A model involving direct and indirect paths from CSA, child and maternal RF to child psychopathology was examined using Mplus software. Results Child mentalization partially mediated the relationships between CSA and depressive symptoms, as well as the relationship between CSA and externalising difficulties. Maternal mentalization was an independent predictor of child externalising difficulties, with higher maternal RF associated with less externalising difficulties. Discussion The findings indicate that by ages 7–12, child mentalization is an important inner resource associated with lower depression and externalising. In addition, this study provides new evidence of the importance of the parents mentalizing stance for the development of self-regulation and externalising difficulties in both abused and non-abused children. The clinical implications are discussed.

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

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

Assessing reflective parenting in interaction with school-aged children

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

A Developmental Psychopathology and Neurobiological Model of Borderline Personality Disorder in Adolescence

The antecedents and risk factors and for developing borderline personality disorder (BPD) are now well documented, but there is a paucity of developmental models to understand the key processes through which they impact on the development of BPD in adolescents. In this article, we present a developmental psychopathology model of BPD in adolescence and link the difficulties adolescents with BPD have with impulsivity and self regulation, with risk factors such as genetic vulnerability, parenting and trauma. We propose a number of psychological processes through which these risk factors undermine personal and interpersonal functioning, and makes it particularly difficult to engage with the challenges of adolescence. These key psychological processes undermine the integration of the self, with extreme unintegrated affects and extreme representations of self and others, undermining the capacity to mentalize. We then make links to possible neurobiological underpinnings of the disturbances in affect, Theory of Mind and interpersonal difficulties in adolescents with BPD.

Transference-Focused Psychotherapy for Personality Disorders in Adolescence

This chapter presents the adaptation of transference-focused psychotherapy for personality disorders in adolescents (TFP-A). This treatment is based on contemporary psychoanalytic object relations theory as developed by Kernberg (1984, 1992) and supported by findings from current evidence-based and neurobiological research (Clarkin, Levy, Lenzenweger, & Kernberg, 2004; Clarkin & Posner, 2005; Doering et al., 2010; Levy et al., 2006). The specificity of the treatment involves assessing dominant pathological object relations activated in the here-and-now interaction with the therapist, as well as engaging the adolescent in a contract that helps him prioritize mentalization and thinking about his motivations rather than acting out. In addition there is a specific approach to dealing with parents in order to create a mental space for the adolescent where he can exercise both autonomy and responsability for his difficulties. Furthermore, the consistent emphasis on intrepreting transference and countertransference reactions is a defining feature of this treatment. The therapist uses these reactions to identify split self- and other-respresentations that prevent integration of the personality and without which the adolescents is not able to use his mentalization capacities in order to deal with the challenges of adolescence. Finally a clinical vignette is presented that illustrates how these principles are applied in the context of the treatment of an adolescent.