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A new self-report measure of mentalization: the Reflective Function Questionnaire Society for Psychotherapy Research Ravenscar Conference, March 25 th.

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Presentation on theme: "A new self-report measure of mentalization: the Reflective Function Questionnaire Society for Psychotherapy Research Ravenscar Conference, March 25 th."— Presentation transcript:

1 A new self-report measure of mentalization: the Reflective Function Questionnaire Society for Psychotherapy Research Ravenscar Conference, March 25 th 2010 Dr. Alesia Perkins Clinical Psychologist 1

2 Acknowledgements This research was conducted in partial fulfilment of a doctorate in Clinical Psychology at the University of Surrey under the supervision of: Prof Peter Fonagy (UCL), author of the RFQ Prof Peter Fonagy (UCL), author of the RFQ Dr. Susan Howard & Dr Fiona Warren (University of Surrey) Dr. Susan Howard & Dr Fiona Warren (University of Surrey) Thanks also go to Dr Rosanna Ghinai who worked on an early version of the measure, and the many clinicians and patients who assisted or participated in the current study. 2

3 Plan 1. Introducing the concept of mentalization and rationale for development of the RFQ 2. The RFQ 3. Method 4. Study 1 Results 5. Study 2 results 6. Discussion and next steps 3

4 1. INTRO Why a self-report measure of mentalization? Treatment of BPD NICE (2009)- Mentalization Based Therapy Treatment of BPD NICE (2009)- Mentalization Based Therapy Measuring mentalization – Reflective Function Rating Scale for Adult Attachment Interview (Fonagy et al, 1998) Measuring mentalization – Reflective Function Rating Scale for Adult Attachment Interview (Fonagy et al, 1998) Pilot study 212 non-clinical participants Pilot study 212 non-clinical participants RFQ46 promising results RFQ46 promising results 4

5 1. INTRO What is mentalization? ‘to hold others’ minds in mind’ as well as one’s own (Fonagy et al., 2002). ‘to hold others’ minds in mind’ as well as one’s own (Fonagy et al., 2002). Operationalised in research as ‘reflective function’ Operationalised in research as ‘reflective function’ Behaviours can be perceived in terms of mental state constructs, thereby making them meaningful, explicable and predictable. Behaviours can be perceived in terms of mental state constructs, thereby making them meaningful, explicable and predictable. Effective mentalization develops in early secure attachment relationships (Fonagy & Target, 1997) Effective mentalization develops in early secure attachment relationships (Fonagy & Target, 1997) Borderline Personality Disorder (Fonagy et al. 1996) Borderline Personality Disorder (Fonagy et al. 1996) 5

6 1. INTRO Handy definitions of Mentalization ‘Holding mind in mind’ ‘Holding mind in mind’ ‘Attending to mental states in self and others’ ‘Attending to mental states in self and others’ ‘Understanding misunderstandings’ ‘Understanding misunderstandings’ ‘Seeing yourself from the outside and others from the inside’ ‘Seeing yourself from the outside and others from the inside’ Allen et al., (2008) 6

7 1. INTRO Research on mentalization in BPD and ED Mentalization lower in BPD and ED (Fonagy et al, 1996) Mentalization lower in BPD and ED (Fonagy et al, 1996) Resilience -Capacity to mentalize can mediate effects of childhood abuse (Fonagy et al, submitted) Resilience -Capacity to mentalize can mediate effects of childhood abuse (Fonagy et al, submitted) Mentalisation Based Therapy effective for BPD - (Bateman & Fonagy, 1999) even 8 years after treatment (Bateman & Fonagy, 2008) Mentalisation Based Therapy effective for BPD - (Bateman & Fonagy, 1999) even 8 years after treatment (Bateman & Fonagy, 2008) Skarderud (2007) initial qualitative work suggests effective for ED also Skarderud (2007) initial qualitative work suggests effective for ED also 7

8 2. The RFQ 46 items (1=strongly disagree - 6=strongly agree) 46 items (1=strongly disagree - 6=strongly agree) Polar-scored items (6 or 1 = high mentalizing) Polar-scored items (6 or 1 = high mentalizing) Median –scored items (3/4=high mentalizing) Median –scored items (3/4=high mentalizing) 123456 Strongly disagree Disagree somewhat Agree Somewhat AgreeStrongly agree 8

9 2. The RFQ examples How strongly do you agree with the following statements: ‘I don’t always know why I do what I do’ (agree/disagree=high RF) ‘I don’t always know why I do what I do’ (agree/disagree=high RF) ‘Strong feelings often cloud my thinking’ (agree/disagree=high RF) ‘Strong feelings often cloud my thinking’ (agree/disagree=high RF) ‘Those close to me often seem to find it difficult to understand why I do things’ (strongly disagree=high RF). ‘Those close to me often seem to find it difficult to understand why I do things’ (strongly disagree=high RF). ‘Sometimes I find myself saying things and I have no idea why I said them’ (strongly disagree=high RF). ‘Sometimes I find myself saying things and I have no idea why I said them’ (strongly disagree=high RF). 9

10 3.METHOD Design and aims of the study Cross-sectional questionnaire-based design Study 1: Assess the psychometric properties of the RFQ in non-clinical and clinical populations (BPD and ED). Study 2: Investigating mentalization and comorbidity, bulimic attitudes and impulsivity 10

11 3.METHOD Sample Sample N=403 PD N=53 Mentalization-based specialist PD team (NHS) Mentalization-based specialist PD team (NHS) 2 independent service-user lead units 2 independent service-user lead units ED N=55 3 NHS specialist ED teams 3 NHS specialist ED teams Non-clinical N=295 Non-academic staff and students at 3 colleges Non-academic staff and students at 3 colleges 11

12 Theory of Mind Reading the Mind in the Eyes Test (Baron-Cohen et al, 2001) Empathy Cognitive subscale of the Basic Empathy Scale (Joliffe & Farrington, 2006) Perspective-Taking Subscale (PTS) of the Interpersonal Reactivity Index (Davies, 1983) Mindfulness Mindful Awareness Attention Scale (MAAS) (Brown & Ryan, 2003) Borderline personality disorder Borderline Personality Inventory (BPI) (Leichsenring, 1999) Zanarini Rating Scale for Borderline Personality Disorder (ZAN) (Zanarini et al. 2003) 3.METHODMeasures 12

13 Disordered eating Eating Attitudes Test (Garner et al, 1982) Impulsivity Multi-Impulsivity Scale (Evans et al, 1998) Depression Beck Depression Inventory-II (Beck et al, 1996) Social desirability Marlowe-Crowne Social Desirability Scale (Crowne & Marlowe, 1960) 3.METHODMeasures 13

14 Mind reading (Reading the Mind in the Eyes Test, Baron-Cohen et al, 2001) joking desire convinced flustered 14

15 Mind reading cautious aghast bored insisting 15

16 4. THE RESULTS Study 1: Psychometric properties of the RFQ 16

17 4. STUDY 1 RESULTS Internal reliability Data screening and exploratory factor analysis on whole sample (N=403) reduced RFQ46 to RFQ15 Data screening and exploratory factor analysis on whole sample (N=403) reduced RFQ46 to RFQ15 Factor structure–Internal mentalization of Self and Other Factor structure–Internal mentalization of Self and Other Test-retest reliability r=.78 Test-retest reliability r=.78 Internal reliability (Cronbach’s alpha=.77) Internal reliability (Cronbach’s alpha=.77) INTERNAL RELIABILITY GOOD 17

18 4. STUDY 1 RESULTS Construct validity +ve ToM, mindfulness and empathy +ve ToM, mindfulness and empathy - ve depression, multi-impulsivity, ED, and BPD. - ve depression, multi-impulsivity, ED, and BPD. Low susceptibility to social desirability effects. Low susceptibility to social desirability effects. RFQ15 more sensitive to psychopathology (ED, BPD, depression, multi-impulsivity) RFQ15 more sensitive to psychopathology (ED, BPD, depression, multi-impulsivity) RFQ46 more sensitive to non-clinical range (empathy, ToM) RFQ46 more sensitive to non-clinical range (empathy, ToM) CONSTRUCT VALIDITY GOOD 18

19 4. STUDY 1 RESULTS Discriminant validity RFQ15 Clinical (M= 33.05) < Non-clinical (M= 39.58) Clinical (M= 33.05) < Non-clinical (M= 39.58) Pre-treatment BPD (M=27.33)< ED (M=34.25) Pre-treatment BPD (M=27.33)< ED (M=34.25) Pre-treatment < post treatment (M=32.02 v M=34.73). Pre-treatment < post treatment (M=32.02 v M=34.73). Highly suggestive discrimination between pre-post treatment, ED/BPD 19

20 4.STUDY 1 RESULTS: Discriminant validity ROC analysis RFQ15 ‘excellent’ discrimination between clin/non-clin (AUC=.88) RFQ15 ‘excellent’ discrimination between clin/non-clin (AUC=.88) Cut-off score 35 (best compromise between sensitivity and specificity) 73% clinical correctly identified.10% non-clin incorrectly ident’ as +ve Cut-off score 35 (best compromise between sensitivity and specificity) 73% clinical correctly identified.10% non-clin incorrectly ident’ as +ve DISCRIMINANT VALIDITY GOOD 20

21 RFQ15 Discriminant validity 21

22 RFQ15 Discriminant validity 22

23 THE RESULTS Study 2: Investigating comorbidity, bulimia and multi- impulsivity 23

24 Given that RF lowest in BPD, the high comorbidity between BN and BPD (O’Brien & Vincent, 2003) and the phenomena of multi-impulsive BN (Lacey & Evans, 1986) hypothesised that mentalization would be lower in: Comorbid than non-comorbid groups BN than AN Multi-impulsives than non-impulsives Study 2 Rationale 24

25 5. STUDY 2 RESULTS: Co-morbidity Mentalization higher in BPD-only group (M=32.19) or ED-only group (M=36.08) than comorbid group (M=28.31) Mentalization higher in BPD-only group (M=32.19) or ED-only group (M=36.08) than comorbid group (M=28.31) MENTALIZATION LOWER IN COMORBID GROUPS 25

26 5.STUDY 2 RESULTS: Bulimia Clin-report diagnosis: mentalization in BN > AN (M=35.44 v M=30.91) Clin-report diagnosis: mentalization in BN > AN (M=35.44 v M=30.91) Self-report: multiple regression only significant predictor of mentalization AN Self-report: multiple regression only significant predictor of mentalization AN (standardised β=-.24, t=-2.00, p=.047) with a large effect size (d=.82) MENTALIZATION LOWER IN AN THAN BN 26

27 5. STUDY 2 RESULTS: Multi-impulsivity Mentalization: Multi-impulsive < non-impulsive (M=29.85 v M=39.91) Mentalization: Multi-impulsive < non-impulsive (M=29.85 v M=39.91) Sobel mediation tests: mentalization significantly mediated the effect of impulsivity on the development of self-report ED (p=.0045)and BPD (p<.0001) traits. Sobel mediation tests: mentalization significantly mediated the effect of impulsivity on the development of self-report ED (p=.0045)and BPD (p<.0001) traits. Mediating effect of mentalization accounted for 19% of the variance in BPD and 10% for ED. Mediating effect of mentalization accounted for 19% of the variance in BPD and 10% for ED. MENTALIZATION MEDIATES IMPULSIVITY 27

28 6. DISCUSSION and NEXT STEPS Psychometric properties of RFQ very promising and merits further development and validation (currently underway) Psychometric properties of RFQ very promising and merits further development and validation (currently underway) Mentalization a multi-dimensional concept Mentalization a multi-dimensional concept Mentalization differs amongst clinical groups Mentalization differs amongst clinical groups Further investigation needed to explain why AN rather than BN associated with lower mentalization Further investigation needed to explain why AN rather than BN associated with lower mentalization 28

29 Questions? Dr. Alesia Perkins alesiaperkins@btinternet.com 29

30 References Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. Arlington, VA: American Psychiatric Publishing Allen, J. G., Fonagy, P., & Bateman, A. W. (2008). Mentalizing in clinical practice. Arlington, VA: American Psychiatric Publishing Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., & Plumb, I. (2001). The “Reading the Mind in the Eyes” test revised version: A study with normal adults, and adults with Asperger Syndrome or high-functioning autism. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 42 (02), 241-251. Baron-Cohen, S., Wheelwright, S., Hill, J., Raste, Y., & Plumb, I. (2001). The “Reading the Mind in the Eyes” test revised version: A study with normal adults, and adults with Asperger Syndrome or high-functioning autism. The Journal of Child Psychology and Psychiatry and Allied Disciplines, 42 (02), 241-251. Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. American Journal of Psychiatry, 156 (10), 1563-1569. Bateman, A., & Fonagy, P. (1999). Effectiveness of partial hospitalization in the treatment of borderline personality disorder: a randomized controlled trial. American Journal of Psychiatry, 156 (10), 1563-1569. Bateman, A., & Fonagy, P. (2008). 8-Year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, March 17, 11-17. Bateman, A., & Fonagy, P. (2008). 8-Year follow-up of patients treated for borderline personality disorder: Mentalization-based treatment versus treatment as usual. American Journal of Psychiatry, March 17, 11-17. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. Texas: The Psychological Corporation. Beck, A. T., Steer, R. A., & Brown, G. K. (1996). Manual for the Beck Depression Inventory-II. Texas: The Psychological Corporation. 30

31 Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84 (4), 822-848. Brown, K. W., & Ryan, R. M. (2003). The benefits of being present: Mindfulness and its role in psychological well-being. Journal of Personality and Social Psychology, 84 (4), 822-848. Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24 (4), 349- 354. Crowne, D. P., & Marlowe, D. (1960). A new scale of social desirability independent of psychopathology. Journal of Consulting Psychology, 24 (4), 349- 354. Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social Psychology, 44 (1), 113-126. Davis, M. H. (1983). Measuring individual differences in empathy: Evidence for a multidimensional approach. Journal of Personality and Social Psychology, 44 (1), 113-126. Evans, C. D. H., Searle, Y., & Dolan, B. M. (1998). Two new tools for the assessment of multi-impulsivity: the MIS and the CAM. European Eating Disorders Review, 6, 48-57. Evans, C. D. H., Searle, Y., & Dolan, B. M. (1998). Two new tools for the assessment of multi-impulsivity: the MIS and the CAM. European Eating Disorders Review, 6, 48-57. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self: Other Press, New York. Fonagy, P., Gergely, G., Jurist, E., & Target, M. (2002). Affect regulation, mentalization, and the development of the self: Other Press, New York. Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., et al. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64 (1), 22-31. Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., et al. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of Consulting and Clinical Psychology, 64 (1), 22-31. 31

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