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

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 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.

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

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

1. INTRO What is mentalization? ‘to hold others’ minds in mind’ as well as one’s own (Fonagy et al., 2002). Operationalised in research as ‘reflective function’ 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) Borderline Personality Disorder (Fonagy et al. 1996)

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

1. INTRO Research on mentalization in BPD and ED Mentalization lower in BPD and ED (Fonagy et al, 1996) 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) Skarderud (2007) initial qualitative work suggests effective for ED also

2. The RFQ 46 items (1=strongly disagree - 6=strongly agree) Polar-scored items (6 or 1 = high mentalizing) Median –scored items (3/4=high mentalizing) 1 2 3 4 5 6 Strongly disagree Disagree somewhat Agree Somewhat Strongly agree

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) ‘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). ‘Sometimes I find myself saying things and I have no idea why I said them’ (strongly disagree=high RF).

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

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

3.METHOD Measures 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.METHOD Measures 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)

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

Mind reading cautious insisting bored aghast

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

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

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

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

4.STUDY 1 RESULTS: Discriminant validity ROC analysis 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 DISCRIMINANT VALIDITY GOOD

RFQ15 Discriminant validity

RFQ15 Discriminant validity

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

Study 2 Rationale 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

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 LOWER IN COMORBID GROUPS

5.STUDY 2 RESULTS: Bulimia Clin-report diagnosis: mentalization in BN > AN (M=35.44 v M=30.91) 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

5. STUDY 2 RESULTS: Multi-impulsivity 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. Mediating effect of mentalization accounted for 19% of the variance in BPD and 10% for ED. MENTALIZATION MEDIATES IMPULSIVITY

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

Questions? Dr. Alesia Perkins alesiaperkins@btinternet.com

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