Nicolas Berthelot

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.

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.

Prevalence and Correlates of Childhood Sexual Abuse in Adults Consulting for Sexual Problems

The main objectives of the study were to assess the prevalence of childhood sexual abuse in individuals consulting for sexual therapy and to explore the association between a history of childhood sexual abuse and psychological and couple functioning. A sample of 218 adults receiving sex therapy completed questionnaires assessing depressive and anxious symptomatology, as well as dyadic adjustment. Prevalence of childhood sexual abuse was high in women (56%) and men (37%), and clients with a history of childhood sexual abuse were more likely to report psychological and relationship problems. Findings should aware clinicians of the need to assess sexual trauma and related outcomes.

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.

Childhood Maltreatment Increases the Risk of Intimate Partner Violence via PTSD and Anger Personality Traits in Individuals Consulting for Sexual Problems

Childhood maltreatment is a significant risk factor for the perpetration of intimate partner violence (IPV) in adulthood. This study tested, in a clinical sample, a conceptual model suggesting that childhood maltreatment contributes to the development of anger personality traits, directly and indirectly via posttraumatic stress disorder (PTSD), and that anger personality traits, in turn, are associated with IPV. Adults consulting for sex therapy (n = 114) completed self-report measures of childhood maltreatment, PTSD, anger, and IPV. Participants were exposed to high rates of childhood maltreatment (83%). Path analysis supported the hypothesized model: Exposure to child maltreatment was associated with anger personality traits, and this association was partially mediated by PTSD symptoms. Anger personality traits were highly correlated with IPV.

Liability indicators aggregate many years before transition to illness in offspring descending from kindreds affected by schizophrenia or bipolar disorder

Objectives Offspring born to patients with affective and non-affective psychoses display indicators of brain dysfunctions that affected parents carry. Such indicators may help understand the risk trajectory. Methods We followed up the clinical/developmental trajectories of 84 young offspring born to affected parents descending from the Quebec kindreds affected by schizophrenia or bipolar disorder. We longitudinally characterized childhood trajectories using 5 established risk indicators: cognitive impairments, psychotic-like experiences, non-psychotic DSM diagnosis and episodes of poor functioning, trauma and drug use. Results Overall, offspring individually presented a high rate of risk indicators with 39% having 3 or more indicators. Thirty-three offspring progressed to an axis 1 DSM-IV disorder, 15 of whom transitioned to a major affective or non-affective disorder. The relative risks for each risk indicator were low in these vulnerable offspring (RR = 1.92 to 2.99). Remarkably, transitioners accumulated more risk indicators in childhood-adolescence than non-transitioners (Wilcoxon rank test; Z = 2.64, p = 0.008). Heterogeneity in the risk trajectories was observed. Outcome was not specific to parents diagnosis. Conclusion Young offspring descending from kindreds affected by major psychoses would accumulate risk indicators many years before transition. A clustering of risk factors has also been observed in children at risk of metabolic-cardiovascular disorders and influences practice guidelines in this field. Our findings may be significant for the primary care surveillance of millions of children born to affected parents in the G7 nations. Future longitudinal risk research of children at genetic risk should explore concurrently several intrinsic and environmental risk modalities to increase predictivity.

Response: Behind the closed doors of mentalizing. A commentary on "Another step closer to measuring the ghosts in the nursery: preliminary validation of the Trauma Reflective Functioning Scale"

In this thought-provoking commentary on our findings regarding the dramatic deficits in mentalization specifically regarding past experiences of abuse and neglect in adults who otherwise demonstrate that they have the capacity to think about past relationships in terms of affects and mental states despite these histories, Schimmenti re-examines our findings from the perspective of dissociation and subtly raises the question of whether we adequately consider dissociative processes in the interpretation of our findings. Starting with Ferenzis early contribution in this regard, Schimmenti points out that dissociative processes are central in reactions to trauma. But what is the relationship between mentalization and dissociation, and more specifically, what is the relationship between mentalization of trauma experiences and dissociation? Recent theoretical and empirical observations suggest that dissociative processes involve a disruption of the normal coordination of affective, memory and cognitive systems, so that unintegrated parallel systems can apparently emerge, with experience being compartmentalized and identity disrupted (Cardena and Carlson, 2011). Initially this separation functions to keep traumatic memories and affects from disrupting functioning (Foa and Hearst-Ideka, 1996). However, when in the long run this contributes to the experience of the self as fragmented, it becomes highly dysfunctional. As Schimmenti observes, this is especially problematic when it contributes to the continued isolation of a tortured part of the self, namely the affective part of the self that is linked to the abuse. We find it particularly useful to think about the relationship between mentalizing and dissociation from a developmental perspective, and from what we are learning from our research with sexually abused children. From a developmental perspective, children would have developed a certain level of mentalization, linked to parental reflective functioning, prior to the experience of trauma such as sexual abuse. We consider that mentalization is central to developing a sense of self and identity and that this sense of self will be an important resilience factor in the context of trauma. When the child can depend on support from parents who are able to consider their psychological experience in the context of trauma this may help them to re-establish self-regulation and trust in others, and reduce recourse to dissociative defenses (Ensink et al., unpublished). However, other individual factors such as temperamentally based variations in the predisposition to hypnotisability (Putnam, 1996) may contribute to differential susceptibility to maintaining dissociative reactions once there is no imminent danger, (Lanius et al., 2006). Not surprisingly, children seem to be particularly vulnerable to dissociation (Diseth, 2005; Jans et al., 2008). While dissociation may initially have been used only to avoid trauma related affects or memories are triggered, children may spend more and more time in a state that is disconnected from reality, and may slip into a parallel world either of phantasy, or where thoughts and feeling are suspended. We have previously described this as a relatively typical developmental phase where pretend does not yet have its quality of partial disconnection from reality, but rather is completely severed from the constraints of the “serious” or “real” (Fonagy et al., 2002). From a more clinical perspective, in the context of therapy with sexually abused children, we observe moments of dissociation where their play is interrupted and suspended, apparently without any abuse related triggers, or even other triggers. It is possible that an emotion was activated that in turn disrupted the motivational system and attentional system. This is consistent with the convergent conclusions by a number of authors that dissociation is an exceedingly complex and multi-faceted phenomenon (Briere et al., 2005) so that any particular research operationalization only ever captures a partial glance. Returning more specifically to our findings with adults who have experienced abuse and neglect, we consider that presently, in the coding and definition of unresolved trauma, dissociative processes are central. Hesse and Main (2000) explicitly make reference to this and describe the momentarily disruptions in cognition and speech production, where in talking about a traumatic experience someone suddenly stops mid-phrase apparently losing the capacity to coordinate and continue speech production or manifest disorientation of person, time and place under the stress of the effort to retrieve trauma related memories. Somewhat surprisingly, in our sample, unresolved trauma, which can be seen as reflecting the potential for dissociation, was not associated with trauma RF. Furthermore, when we examined the implications of trauma RF and unresolved trauma in mothers for infant attachment organization, we have found that both make independent contributions to infant attachment organization (Berthelot et al., 2015). In addition, when we have examined the relationship between RF and dissociation in sexually abused children and adults from the community, we have found that there is a weak to moderate correlation between general RF or mentalization capacities about self and others and scores on questionnaire measures of dissociation (Ensink et al., unpublished). Put differently, what these findings may be suggesting is that when asked to think about trauma, someone may dissociate when overwhelmed by un-metabolized trauma related memories and affects, while also attempting to mentalize. Mentalizing and dissociative processes may thus occur simultaneously in parallel and may be only loosely connected. Interestingly, findings by Lanius et al. (2010) indicate that dissociative responses like detachment, subjective distancing, depersonalization and derealization associated with overmodulation of affect in response to autobiographical trauma memories are mediated by increased medial prefrontal and rostral anterior cingulate activation and decreased amygdala and right anterior insula activation. Considering that mentalization as we are measuring it, involves coordination by prefrontal and temporo-parietal systems (Fonagy and Luyten, 2009), this suggests that closely related neurobiological system are involved in the two processes. If there are different, though to some extend interacting, developmental pathways to mentalization and dissociation, this may explain why we do not see the association between unresolved trauma and trauma RF as we may have intuitively expected. However, we expect that when mentalization is supported in the context of relationships of trust, such as therapeutic relationships, mentalization may be used to become aware of dissociative experiences, metabolize them to some extend and make them more tolerable. Until this is studied longitudinally we can only speculate regarding the direction of the relationships, but we hypothesize that children with better mentalization capacities may be less likely to dissociate. At the same time, pervasive dissociation when children are not connected to reality and miss out on opportunities to engage in relationship where they can learn about their own minds and that of others, can also be expected to undermine the development of mentalization capacities. However, before coming to the conclusion that dissociation is necessarily bad, it is possible that at low levels, dissociation can have adaptive value in everyday life and can actually support emotional regulation and creativity by inhibiting thinking about disturbing experiences (Butler, 2006). We hope that our response to this commentary will stimulate further reflection and research into dissociation and mentalization and risk and resilience in the context of abuse.

Dissociation mediates the relationship between sexual abuse and child psychological difficulties

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