A new self-report A new self-report measure of measure of

mentalization: the mentalization: the Reflective Function Reflective Function

QuestionnaireQuestionnaire

Society for Psychotherapy Society for Psychotherapy Research Ravenscar Conference, Research Ravenscar Conference,

March 25March 25thth 2010 2010Dr. Alesia Perkins Clinical Dr. Alesia Perkins Clinical PsychologistPsychologist

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AcknowledgementsAcknowledgements

This research was conducted in partial fulfilment This research was conducted in partial fulfilment of a doctorate in Clinical Psychology at the of a doctorate in Clinical Psychology at the University of Surrey under the supervision of:University of Surrey under the supervision of:

Prof Peter Fonagy (UCL), author of the RFQProf Peter Fonagy (UCL), author of the RFQ Dr. Susan Howard & Dr Fiona Warren Dr. Susan Howard & Dr Fiona Warren

(University of Surrey) (University of Surrey)

Thanks also go to Dr Rosanna Ghinai who worked Thanks also go to Dr Rosanna Ghinai who worked on an early version of the measure, and the on an early version of the measure, and the many clinicians and patients who assisted or many clinicians and patients who assisted or participated in the current study.participated in the current study.

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PlanPlan

1.1. Introducing the concept of Introducing the concept of mentalization and rationale for mentalization and rationale for development of the RFQdevelopment of the RFQ

2.2. The RFQThe RFQ

3.3. MethodMethod

4.4. Study 1 ResultsStudy 1 Results

5.5. Study 2 resultsStudy 2 results

6.6. Discussion and next stepsDiscussion and next steps

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1. INTRO1. INTROWhy a self-report Why a self-report

measure of measure of mentalization?mentalization? Treatment of BPD NICE (2009)- Treatment of BPD NICE (2009)-

Mentalization Based TherapyMentalization Based Therapy Measuring mentalization – Reflective Measuring mentalization – Reflective

Function Rating Scale for Adult Function Rating Scale for Adult Attachment Interview (Fonagy et al, Attachment Interview (Fonagy et al, 1998)1998)

Pilot study 212 non-clinical Pilot study 212 non-clinical participantsparticipants

RFQ46 promising resultsRFQ46 promising results 4

1. INTRO1. INTROWhat is mentalization?What is mentalization?

‘‘to hold others’ minds in mind’ as well as to hold others’ minds in mind’ as well as one’s own (Fonagyone’s own (Fonagy et al. et al., 2002). , 2002).

Operationalised in research as ‘reflective Operationalised in research as ‘reflective function’function’

Behaviours can be perceived in terms of Behaviours can be perceived in terms of mental state constructs, thereby making mental state constructs, thereby making them meaningful, explicable and them meaningful, explicable and predictable. predictable.

Effective mentalization develops in early Effective mentalization develops in early secure attachment relationships (Fonagy & secure attachment relationships (Fonagy & Target, 1997)Target, 1997)

Borderline Personality Disorder (Fonagy et Borderline Personality Disorder (Fonagy et al. 1996)al. 1996) 5

1. INTRO1. INTROHandy definitions of Handy definitions of

MentalizationMentalization ‘‘Holding mind in mind’Holding mind in mind’ ‘‘Attending to mental states in self Attending to mental states in self

and others’and others’ ‘‘Understanding misunderstandings’Understanding misunderstandings’ ‘‘Seeing yourself from the outside Seeing yourself from the outside

and others from the inside’and others from the inside’

Allen et al., (2008)Allen et al., (2008)6

1. INTRO1. INTROResearch on mentalization Research on mentalization

in BPD and EDin BPD and ED Mentalization lower in BPD and ED Mentalization lower in BPD and ED

(Fonagy et al, 1996) (Fonagy et al, 1996) Resilience -Capacity to mentalize can Resilience -Capacity to mentalize can

mediate effects of childhood abuse mediate effects of childhood abuse (Fonagy et al, submitted)(Fonagy et al, submitted)

Mentalisation Based Therapy effective for Mentalisation Based Therapy effective for BPD - (Bateman & Fonagy, 1999) even 8 BPD - (Bateman & Fonagy, 1999) even 8 years after treatment (Bateman & Fonagy, years after treatment (Bateman & Fonagy, 2008)2008)

Skarderud (2007) initial qualitative work Skarderud (2007) initial qualitative work suggests effective for ED alsosuggests effective for ED also

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2. The RFQ2. The RFQ

46 items (1=strongly disagree - 46 items (1=strongly disagree - 6=strongly agree)6=strongly agree)

Polar-scored items (6 or 1 = high Polar-scored items (6 or 1 = high mentalizing)mentalizing)

Median –scored items (3/4=high Median –scored items (3/4=high mentalizing) mentalizing)

1 2 3 4 5 6

Stronglydisagree

Disagree Disagreesomewhat

Agree Somewhat

Agree Strongly agree

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2. The RFQ examples2. The RFQ examplesHow strongly do you agree with the following How strongly do you agree with the following

statements:statements: ‘‘I don’t always know why I do what I doI don’t always know why I do what I do’ ’

(agree/disagree=high RF)(agree/disagree=high RF) ‘‘Strong feelings often cloud my thinking’ Strong feelings often cloud my thinking’

(agree/disagree=high RF)(agree/disagree=high RF) ‘‘Those close to me often seem to find it difficult to Those close to me often seem to find it difficult to

understand why I do things’ understand why I do things’ (strongly disagree=high (strongly disagree=high RF).RF).

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

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3.METHOD3.METHOD Design and aims of the Design and aims of the

studystudyCross-sectional questionnaire-based Cross-sectional questionnaire-based

design design

Study 1: Assess the psychometric Study 1: Assess the psychometric properties of the RFQ in non-clinical properties of the RFQ in non-clinical and clinical populations (BPD and ED). and clinical populations (BPD and ED).

Study 2: Investigating mentalization and Study 2: Investigating mentalization and comorbidity, bulimic attitudes and comorbidity, bulimic attitudes and impulsivityimpulsivity

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3.METHOD 3.METHOD SampleSample

Sample N=403 Sample N=403

PD N=53PD N=53 Mentalization-based specialist PD team (NHS)Mentalization-based specialist PD team (NHS) 2 independent service-user lead units2 independent service-user lead units

ED N=55ED N=55 3 NHS specialist ED teams3 NHS specialist ED teams

Non-clinical N=295Non-clinical N=295 Non-academic staff and students at 3 collegesNon-academic staff and students at 3 colleges

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Theory of MindReading the Mind in the Eyes Test (Baron-Cohen et al, 2001)

EmpathyCognitive subscale of the Basic Empathy Scale (Joliffe & Farrington, 2006)Perspective-Taking Subscale (PTS) of the Interpersonal Reactivity Index (Davies, 1983)

MindfulnessMindful Awareness Attention Scale (MAAS) (Brown & Ryan, 2003)

Borderline personality disorderBorderline Personality Inventory (BPI) (Leichsenring, 1999) Zanarini Rating Scale for Borderline Personality Disorder (ZAN) (Zanarini et al. 2003)

3.METHODMeasuresMeasures

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Disordered eatingEating Attitudes Test (Garner et al, 1982)

Impulsivity Multi-Impulsivity Scale (Evans et al, 1998)

DepressionBeck Depression Inventory-II (Beck et al, 1996)

Social desirabilityMarlowe-Crowne Social Desirability Scale (Crowne & Marlowe, 1960)

3.METHODMeasuresMeasures

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Mind reading Mind reading

(Reading the Mind in the Eyes Test, Baron-Cohen et (Reading the Mind in the Eyes Test, Baron-Cohen et al, 2001)al, 2001)

joking

desire convinced

flustered

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Mind readingMind reading

cautious

aghastbored

insisting

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4. THE RESULTS

Study 1: Psychometric properties of the RFQ

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4. STUDY 1 RESULTS4. STUDY 1 RESULTS Internal reliability Internal reliability

Data screening and exploratory Data screening and exploratory factor analysis on whole sample factor analysis on whole sample (N=403) reduced RFQ46 to RFQ15 (N=403) reduced RFQ46 to RFQ15

Factor structure–Internal Factor structure–Internal mentalization of mentalization of Self Self and and OtherOther

Test-retest reliability r=.78Test-retest reliability r=.78 Internal reliability (Cronbach’s Internal reliability (Cronbach’s

alpha=.77)alpha=.77)INTERNAL RELIABILITY GOOD

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4. STUDY 1 RESULTS4. STUDY 1 RESULTSConstruct validityConstruct validity

+ve ToM, mindfulness and empathy +ve ToM, mindfulness and empathy - ve depression, multi-impulsivity, ED, and - ve depression, multi-impulsivity, ED, and

BPD. BPD. Low susceptibility to social desirability Low susceptibility to social desirability

effects. effects. RFQ15 more sensitive to psychopathology RFQ15 more sensitive to psychopathology

(ED, BPD, depression, multi-impulsivity)(ED, BPD, depression, multi-impulsivity) RFQ46 more sensitive to non-clinical range RFQ46 more sensitive to non-clinical range

(empathy, ToM)(empathy, ToM)

CONSTRUCT VALIDITY GOOD

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4. STUDY 1 RESULTS 4. STUDY 1 RESULTS Discriminant validityDiscriminant validity

RFQ15 RFQ15 Clinical (M= 33.05) < Non-clinical (M= Clinical (M= 33.05) < Non-clinical (M=

39.58)39.58) Pre-treatment BPD (M=27.33)< ED Pre-treatment BPD (M=27.33)< ED

(M=34.25)(M=34.25) Pre-treatment < post treatment (Pre-treatment < post treatment (MM=32.02 v =32.02 v

MM=34.73). =34.73).

Highly suggestive discrimination between Highly suggestive discrimination between pre-post treatment, ED/BPD pre-post treatment, ED/BPD

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4.STUDY 1 RESULTS: 4.STUDY 1 RESULTS: Discriminant validityDiscriminant validity

ROC analysis ROC analysis RFQ15 ‘excellent’ discrimination between RFQ15 ‘excellent’ discrimination between

clin/non-clin (AUC=.88)clin/non-clin (AUC=.88) Cut-off score 35 (best compromise between Cut-off score 35 (best compromise between

sensitivity and specificity) 73% clinical sensitivity and specificity) 73% clinical correctly identified.10% non-clin incorrectly correctly identified.10% non-clin incorrectly ident’ as +veident’ as +ve

DISCRIMINANT VALIDITY GOOD

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RFQ15 Discriminant RFQ15 Discriminant validityvalidity

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RFQ15 Discriminant RFQ15 Discriminant validityvalidity

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THE RESULTS

Study 2: Investigating comorbidity, bulimia and multi-impulsivity

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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 RationaleStudy 2 Rationale

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5. STUDY 2 RESULTS: 5. STUDY 2 RESULTS: Co-morbidityCo-morbidity

Mentalization higher in BPD-only Mentalization higher in BPD-only group (group (MM=32.19) or ED-only group =32.19) or ED-only group ((MM=36.08) than comorbid group =36.08) than comorbid group ((MM=28.31)=28.31)

MENTALIZATION LOWER IN COMORBID GROUPS

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5.STUDY 2 RESULTS:5.STUDY 2 RESULTS:BulimiaBulimia

Clin-report diagnosis: mentalization Clin-report diagnosis: mentalization in BN > AN (in BN > AN (MM=35.44 v =35.44 v MM=30.91)=30.91)

Self-report: multiple regression only Self-report: multiple regression only significant predictor of mentalization significant predictor of mentalization ANAN

(standardised (standardised ββ=-.24,=-.24, t t=-2.00, =-2.00, pp=.047) with a large effect size =.047) with a large effect size ((dd=.82)=.82)MENTALIZATION LOWER IN AN THAN

BN

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5. STUDY 2 RESULTS: 5. STUDY 2 RESULTS: Multi-impulsivityMulti-impulsivity

Mentalization: Multi-impulsive < Mentalization: Multi-impulsive < non-impulsive (non-impulsive (MM=29.85 v =29.85 v MM=39.91)=39.91)

Sobel mediation tests: mentalization Sobel mediation tests: mentalization significantly mediated the effect of significantly mediated the effect of impulsivity on the development of impulsivity on the development of self-report ED (self-report ED (pp=.0045)and BPD =.0045)and BPD ((pp<.0001) traits. <.0001) traits.

Mediating effect of mentalization Mediating effect of mentalization accounted for 19% of the variance in accounted for 19% of the variance in BPD and 10% for ED.BPD and 10% for ED.MENTALIZATION MEDIATES

IMPULSIVITY

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6. DISCUSSION and NEXT 6. DISCUSSION and NEXT STEPSSTEPS

Psychometric properties of RFQ very Psychometric properties of RFQ very promising and merits further promising and merits further development and validation (currently development and validation (currently underway)underway)

Mentalization a multi-dimensional Mentalization a multi-dimensional conceptconcept

Mentalization differs amongst clinical Mentalization differs amongst clinical groupsgroups

Further investigation needed to explain Further investigation needed to explain why AN rather than BN associated with why AN rather than BN associated with lower mentalizationlower mentalization

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Questions?Questions?

Dr. Alesia PerkinsDr. Alesia Perkins

alesiaperkins@btinternet.comalesiaperkins@btinternet.com

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