Background: Empirical evidence suggests a relationship between early trauma and psychosis. However, the underlying mechanisms for this relationship remain unclear. Research into metacognitive functioning in psychosis indicates higher levels of metacognitive dysfunctional beliefs within this patient group. The potential effects of early trauma on metacognitive functioning in psychosis has to date been scarcely researched. Reflective functioning (RF) is believed to be affected by early trauma and leading to psychopathology, particularly borderline personality disorder. However, to date no studies have investigated the effects of early trauma on RF within psychosis. Objectives: The primary aim of this study was to establish core links between the effects of early trauma and metacognitive and reflective functioning in psychosis. A secondary aim was to test the clinical applicability of a brief, newly developed attachment-based measure for RF. Furthermore, the study aimed to explore potential overlaps between the concepts of metacognition and reflective functioning. Method: A quantitative methodology was employed, using a combination of semi-structured interviews and self-report questionnaire, and group comparisons were conducted. Twenty-seven patients with psychosis or bipolar disorder were recruited. Participants were grouped into early trauma versus no early trauma; trauma versus no trauma; and in-patient versus out-patient, and exploratory analyses were completed. Results: No significant effects were found for early trauma but for trauma in general, indicating higher level of dysfunctional beliefs in patients with trauma (early plus adult trauma) history. No significant effect between groups were found for RF. Inpatients, however, showed significantly lower levels of RF when compared with outpatients, and outpatients significantly higher levels of cognitive self-focus(thinking about thoughts). Moreover, a modest positive correlation was found between both measures. Discussion: The findings of the present study suggest core links between the effects of trauma on metacognitive functioning in psychosis. This highlights the importance of routine trauma assessment with psychotic patients. The limitations of the metacognitive model within psychosis are discussed. Further research is implicated to investigate any potential effects of early trauma on RF in psychosis. Low level of RF in in-patients highlights the importance to integrate therapeutic techniques to improve RF functioning in this patient group since high RF is associated with resilience and better therapy outcome. The correlation between metacognition and RF measure indicates construct-validity for the RF measure. The differences between both concepts are considered. Furthermore, the limitations of this study and clinical utility are discussed along with suggestions for future research.

Introduction: A systematic review was undertaken to identify any psychological predictors of treatment dropout for individuals diagnosed with an eating disorder, to help inform psychological therapy and reduce attrition. An empirical study was conducted to understand developmental psychological mechanisms at play in the aetiology and maintenance of eating disordered symptomology by assessing reflective functioning and attachment from a trans-diagnostic perspective. Methods: Twenty-one papers were identified through a systematic search of databases using predefined extraction criteria, identifying psychological predictors of treatment dropout in eating disorders. Fourteen female adolescents with a diagnosis of an eating disorder were recruited to the empirical study from CAMHS inpatient and outpatient departments in NHS Scotland, as well as eighteen same age controls from local secondary schools. Participants completed questionnaires regarding eating behaviour, difficulties in emotion regulation, reflective functioning and were interviewed using the Adult Attachment Projective. Results: The systematic review revealed varied psychological predictors of dropout falling onto a continuum ranging from maturity fears to interpersonal difficulties. Results did not significantly differ for inpatient or outpatient treatment or diagnosis. The empirical study found adolescents with an eating disorder to have significantly more difficulties with their emotion regulation and reflective functioning as well as a more insecure attachment style when compared to controls, none of which were weight dependent. Conclusion: Further research is required to operationalise a definition of dropout. Although eating disorders can be seen as a defence mechanism to control and avoid emotional distress, this actually exacerbates them and causes disengagement from treatment. Clinical interventions need to focus on therapeutic rapport from the outset of treatment in order to reduce interpersonal difficulties leading to attrition. The results of the empirical study support the use of early intervention and person centred therapies for adolescents with an eating disorder, even when acutely starved. Specifically therapies that target reflective functioning and take insecure attachment styles into account may improve psychological efficacy and engagement.

No description available.

Mentaliseringsförmåga handlar om att kunna begripliggöra egna och andras beteenden och sinnestillstånd i termer av bakomliggande mentala tillstånd. Enligt mentaliseringsteorin är brister i detta grundproblemet vid borderline personlighetssyndrom (BPS) men kan också tänkas vara en delförklaring till substansberoende, vilket är vanligt förekommande i patientgruppen. Mentaliseringsbaserad terapi skulle därför kunna vara en effektiv behandlingsform som tillägg till sedvanlig beroendevård för patienter med båda diagnoserna. Föreliggande studie har jämfört behandlingsutfall i termer av mentaliseringsförmåga, operationaliserat som reflective functioning (RF), efter behandling med mentaliseringsbaserad terapi (MBT) i tillägg till sedvanlig behandling för substansberoende (TAU) (N = 12) jämfört med enbart TAU (N = 10) för patienter med BPS och samtidigt substansberoende. En ANOVA visade inte på några skillnader avseende förändring i RF mellan grupperna och inte heller någon förändring i RF efter behandling. Patienter med dubbeldiagnos kan tänkas vara en population där MBT inte har önskad effekt på RF, men nollresultatet kan också tänkas bero på metodologiska tillkortakommanden.

There is evidence that functions related to attachment may play an important role in the etiology and maintenance of eating disorders, particularly anorexia and bulimia nervosa (Kuipers & Bekker, 2012; Tasca & Balfour, 2014). However, there is little research available on attachment functioning in those with binge-eating disorder (BED). This dissertation consists of three studies that examine the role of attachment states of mind and attachment dimensions in understanding BED and co-morbid overweight, and to examine mechanisms related to group treatment response for those with BED. The first study assessed attachment state of mind classifications (i.e., attachment categories) to understand better: 1) the psychopathology and maintenance of BED and co-morbid overweight, and 2) the treatment response of women with BED who receive Group Psychodynamic Interpersonal Psychotherapy (GPIP; Tasca, Mikail, & Hewitt, 2005). Overweight women with BED (subsequently referred to as women with BED), overweight women without BED, and normal weight women without BED completed the Adult Attachment Interview (AAI; Main, Goldwyn, & Hesse, 2002). Those with BED completed the AAI pre- and six months post- GPIP and those without BED completed the AAI at one-time point. Women with BED have significantly higher rates of insecure (preoccupied) and unresolved/disorganized attachment states of mind compared to normal weight women without BED. Women with BED had similar rates of insecure and unresolved/disorganized attachment states of mind as overweight women without BED. With respect to treatment completers, changes in attachment states of mind were not statistically significant. However, follow-up analyses indicated clinically meaningful changes which are discussed in the study. The second study used attachment dimensions of coherence of mind and reflective functioning (measured using the AAI) to add to our understanding of the psychopathology and maintenance of BED and co-morbid overweight. Higher Reflective Functioning scores differentiated normal weight women from both women with BED and overweight women without BED, and the latter two groups did not differ from each other. Coherence of Mind scores did not differentiate the groups. The third study used attachment dimensions of coherence of mind and reflective functioning to understand better group psychotherapy response for those with BED who received GPIP. Greater reflective functioning at pre-treatment was associated with a decline in binge eating frequency at 12 months post-treatment. Pre-treatment levels of coherence of mind was not related to group treatment outcomes. Reflective Functioning scores significantly improved from pre- to six months post-treatment. Further, more than 39% of participants demonstrated clinically reliable improvement and almost 32% experienced clinically reliable recovery with respect to reflective functioning. These results were moderated by pre-treatment self-reported attachment anxiety. That is, those with lower attachment anxiety showed significant improvement in reflective functioning, whereas those with higher attachment anxiety did not show this improvement. A third of participants experienced clinically significant improvement in coherence of mind, but this change was not statistically significant. Overall, attachment dimensions and attachment state of mind classification contribute to our understanding of the etiology and maintenance of BED and co-morbid overweight, as well as to our understanding of the group treatment response of those with BED. Addressing attachment insecurity and low reflective functioning in those with BED may improve treatment outcomes.

In many conflict regions, women and girls continue to be at high risk of becoming victims of rape by armed combatants, whether local or foreign militaries, rebel groups or peace keeping forces. The physical and psychological repercussions of CRSV against women and their families can be long-lasting and far-reaching (Bosmans, 2007); and it is by no accident that sexual violence is now widely referred to as a ‘weapon of war’ (Clifford, 2008) or an ‘act of terrorism’ (United Nations, 2017). Very often, social taboos dictate that victims of sexual violence be seen as unclean, spoiled or unfaithful, which can lead to social isolation and stigmatisation (Albutt, Kelly, Kabanga, & VanRooyen, 2016). Injuries and trauma from sexual violence may also raise the concern that women are not be able to work, perform household chores or care for children; effectively diminishing their perceived ‘worth’ (Glass, Ramazani, Tosha, Mpanano, & Cinyabuguma, 2012). Depression and other mental illnesses may create further barriers with family and friends and diminish participation in wider community life (Betancourt, Agnew-Blais, Gilman, Williams, & Eliis, 2010). Raising a child born from CRSV can add to this burden, and these dyads may face further barriers to secure attachments. This may arise as a result of a mother’s own emotion dysregulation following the trauma of sexual violence or indeed ambivalence towards their child as a result of his/her conception. Such dyadic victimhood may also be compounded by migration and assimilation into a new culture. And yet, women do not (always) see themselves as victims, many women seem themselves as brave and courageous (Medica Zenica & medica mondiale, 2014). Many are able to achieve growth in spite of their experiences. The overarching aim of this dissertation is to contribute to the discourse on the myriad psychosocial outcomes of conflict-related sexual violence for survivors, by systematically exploring areas of difficulty and areas of perceived strength and combining mixed methodologies. It is built on the foundation of multiple intertwining areas of global mental health and explored several of these within two different contexts: being a mother, being a survivor. Using the evidence generated through this dissertation, recommendations for addressing their needs have been provided.:Foreword 4 Introduction 5 Background & Context 6 Outcomes of CRSV Against Women: Being a Mother, Being a Survivor 8 Aims & Objectives 12 Research Questions 12 Core Publications of this Dissertation 13 Chapter I: Being a Mother 14 Methodology 15 Publication I 21 Publication II 36 Chapter II: Being a Survivor 57 Methodology 58 Publication III 63 A Dual Model of Posttraumatic Stress and Posttraumatic Growth in Survivors of Sexual Violence 76 Publication IV 77 Discussion 103 Summary of Findings 104 Strengths and Limitations 107 Conclusion 108 Future directions 111 Recommendations 113 Thesis References 134 Appendices 141 1. Abbreviations 142 2. Zusammenfassung 143 3. This dissertation is based on the following publications 145 4. Presentation of own contribution 146 6. Curriculum Vitae 148 7. Publication List 149 8. Certificate of Good Scientific Practice 151 9. Acknowledgements 152

The ability of a parent to step back from their own experiences in order to understand those of their child, reflective functioning (RF), can be impacted by myriad factors. We explored RF among refugee mothers in the context of having a child born of sexual violence (CBSV). A sample of 10 mothers now residing in the Netherlands, both with (n = 5) and without (n = 5) a CBSV, were interviewed, seeking to explore parents’ representations of their children, themselves as parents, and their relationship with their children. After deriving a score of RF, interview narratives were qualitatively analyzed using thematic analysis. An ordinary level of reflective functioning was identified in this sample overall (average score 4.5); which was reduced in the group with CBSV (average score 3.0). Trends within the qualitative analyses indicated that emotion regulation and ambivalence as well as parenting challenges are factors that affect RF capabilities for mothers with CBSV. Wider findings show that the asylum process and mental well-being also impinge on RF capabilities. Experiences of having a CBSV as well as those pertaining to being a refugee appear to interact and impact reflective functioning for some mothers. Further investigation would add weight to this pilot data.

Unresolved adverse and traumatic experiences in parents can amplify the risk of perpetuating intergenerational transmission of trauma. Parents’ positive and adaptive practices such as self-care might act as a protective factor against this ripple effect. This study investigated whether self-care moderated the relationship between parental ACEs, post-traumatic stress symptoms, and parental reflective functioning in mothers who are experiencing high psychosocial stress (n = 59) residing in rural Appalachia. Within our sample, there was no statistically significant linear relationship between our predictors, ACE score and PTSD symptoms, and our outcome of interest, maternal pre-mentalizing. We did not find empirical support for self-care serving as a protective factor in the context of ACEs and PTSD symptoms. Despite the null findings in the main study hypotheses, the results of this study contribute to the literature on maternal trauma history and parenting outcomes. Implications, limitations, and future directions are discussed.

Therapists’ reactions towards patients are important for the therapeutic process, and is influenced by therapist and patient characteristics. This study aimed to improve the understanding of therapists’ emotional reactions by investigating if patients’ attachment and ability to mentalize predicted therapist countertransference in psychotherapy. Multilevel modeling was used to analyse 87 therapy-dyads in psychotherapy. Patient attachment, measured pre-treatment using self-reports, and mentalization operationalized as Reflective functioning (RF) were hypothesized to predict therapist self-reported emotional experiences (conceptualized as countertransference) over the complete treatment and in different treatment phases. Results showed that lower patient RF predicted more negative therapist countertransference in complete treatment. In the middle and final phases of therapy, lower RF predicted more negative countertransference, and higher RF predicted more positive countertransference. Higher level of avoidant attachment in patients predicted more relaxed therapist countertransference in the final phase of treatment. Findings indicate that patients’ mentalizing ability is important to consider in psychotherapy, as it has informational value for the therapeutic process. / Terapeuters reaktioner gentemot patienter är en viktig del i den psykoterapeutiska processen, och påverkas av terapeuters och patienters personliga egenskaper. Den här studien syftade till att utvidga förståelsen för terapeuters känslomässiga reaktioner genom att undersöka om patienters anknytning och mentaliseringsförmåga predicerar terapeuters motöverföring i psykoterapi. Multilevel-modeling användes för att analysera 87 behandlingsdyader i psykoterapi. Patienters anknytning, mätt innan behandling genom självskattning, och mentalisering operationaliserat som reflektivt fungerande (RF) förväntades predicera terapeuters självskattade emotionella upplevelser (konceptualiserat som motöverföring) över hela behandlingsperioden och i olika behandlingsfaser. Resultaten visade att lägre RF hos patienter predicerade mer negativ motöverföring hos terapeuter över hela behandlingsperioden. I mitten- och slutfaserna av terapin predicerade lägre RF mer negativ motöverföring, och högre RF predicerade mer positiv motöverföring. Högre nivåer av undvikande anknytning hos patienter predicerade mer avslappnad motöverföring hos terapeuter i slutfasen. Fynden indikerar att patienters mentaliseringsförmåga är viktigt att beakta i psykoterapi, eftersom det har informativt värde för den terapeutiska processen.

<p>The objective of this work was to investigate reflective-functioning (RF) as a measure of process in two independent studies that included three types of brief psychotherapy. RF is defined as the ability to recognize the existence and nature of mental processes taking place in the self and in others (e.g., intentions, beliefs, desires, and wishes). Theorists have suggested the ability for RF is crucial for predicting social causality and low RF has been found related to mental disorders. It has recently been suggested in the literature that improved ability for RF might be an important component of successful psychotherapy outcome, especially with respect to achieving structuralchange. RF was in this work investigated during the process through discourse analysis of the patients’ narratives of self-other interactions in the treatment sessions. The Psychotherapy Process Q-set (PQS) was implemented in order to isolate specific components of the process (process correlates) that identified high and low RF and to investigate the links between the process correlates and outcome. The first study investigated 29 cases of cognitive-behavioral therapy(CBT) and 35 cases of interpersonal psychotherapy (IPT) with an average treatment length of 16.2 sessions in a sample from the National Institute of Mental Health (NIMH) randomized clinical trial Treatment of Depression Collaborative Research Program (TDCRP). The sample in the first study consisted of 128 sessions in total, were one session from the early part (on average the 4th session) and one session in the later part of the treatment (on average the 12th session) were rated for RF. The second study investigated a sample of 30 cases of brief psychodynamic psychotherapy (BPDT) with an average treatment length of 15.8 sessions in a naturalistic designand obtained from the Mount Zion Psychotherapy Research Group. In total, the second study included 90 sessions of BPDT, and RF was assessed during the 1st, the 5th, and the 14th session of each treatment. The results from these two studies suggested that the patients’ ability for RF, as measured through the discourse from therapy sessions, is stable (in CBT and BPDT) or decreased(IPT) during the treatments. Furthermore, the process correlates defining high RF had a relation with good outcome, and process correlates defining low RF had a relation with poor outcome.The process correlates identified during the PQS-analysis suggested that both high and low RF was linked with personality characteristics in the patients. For example, high RF was linked to patients’ ability for introspection, expression of negative emotions, and commitment to treatment.Low RF was linked to patients’ expression of passivity, defensiveness, and suspiciousness. This work supported theorists’ suggestions that brief treatments are supportive in their nature and therefore do not promote structural changes (e.g., changes in RF). It is suggested that the abilityfor RF as assessed pre-treatment might be a useful predictor for success in brief psychotherapy and could therefore be used as a patient inclusion criteria for such treatments.</p>