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    Interaction structures as predictors of outcome in a naturalistic study of psychodynamic child psychotherapy
    (Routledge Journals, Taylor & Francis Ltd, 2020) Halfon, Sibel; Goodman, Geoff; Bulut, Pelinsu
    Objective: The first aim of this study was to identify interaction structures (IS), which refer to clusters of items characterizing the course of psychotherapy in terms of reciprocal interaction patterns between the therapist and the child, secondly to assess their trends over the course of treatment, and finally investigate which IS predict outcome in long-term psychodynamic child psychotherapy. Method: The sample included 52 children with externalizing and internalizing problems. 192 sessions were rated with the use of the Child Psychotherapy Q-Set (CPQ). Outcome was assessed with the Child Behavior Checklist (CBCL) Total Problems, and Children's Global Assessment Scale (CGAS). Results: A principal components analysis resulted in four IS, theoretically named Therapeutic Alliance, Children's Emotion Expression, Child -Centered Technique and Psychodynamic Technique. Multilevel Modeling (MLM) analyses indicated significant linear growth on Psychodynamic Technique. Multiple regression analyses indicated that Psychodynamic Technique positively predicted changes on CBCL Total Problems and CGAS. In contrast, Child-Centered technique negatively predicted change on CBCL Total Problems, however follow up interaction analyses showed that externalizing children who received more Child-Centered technique showed more improvement on this scale. Discussion: Findings point to empirically derived components of psychodynamic child psychotherapy and provide preliminary answers about which aspects may facilitate change.
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    Mentalization and the growth of symbolic play and affect regulation in psychodynamic therapy for children with behavioral problems
    (Routledge Journals, Taylor & Francis Ltd, 2019) Halfon, Sibel; Bulut, Pelinsu
    Objective: Children with behavioral problems often have problems with symbolic play organization, specifically with the regulation of negative affect and its representation. One of the aims of psychodynamic therapy with these children is enhancing their symbolic and mentalizing capacities in play. This study investigated the associations between promoting mentalization, and the growth of symbolic play and affect regulation. Method: The sample included 48 children with behavioral problems, who underwent long-term psychodynamic treatment informed with mentalization principles, with good outcome. Three hundred twenty-nine sessions were coded for children's symbolic play and affect regulation strategies, and each treatment was rated for adherence to mentalizing principles. Results: Hierarchical linear modeling showed quadratic growth of variables, wherein symbolic play initially increased followed by a deceleration in change, whereas affect regulation initially decreased followed by an increase. Adherence to mentalizing principles was associated with both symbolic play and affect regulation. A two-way interaction between time in treatment and adherence to mentalization showed that in high adherent treatments, affect regulation increased towards the end of treatment, whereas in low adherent treatments, there was no change. Conclusion: Results show support for the association between adherence to mentalization and growth of affect regulation and symbolic play in psychodynamic therapy.
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    The Efficacy of Mentalization-Based Treatment for Children With Internalizing and Externalizing Problems: A Randomized Controlled Trial
    (Elsevier Science Inc, 2025) Halfon, Sibel; Besiroglu, Burcu; Bulut, Pelinsu; Epozdemir, Sevin; Aydin, Gizem I.; Koc, H. Burak; Midgley, Nick
    Objective: High comorbidity in childhood emotional and behavioral disorders calls for transdiagnostic interventions that can address both internalizing and externalizing problems. Mentalization-Based Treatment for Children (MBT-C) is a transdiagnostic, time-limited individual child psychotherapy with parallel parent sessions that aims to promote mentalization and emotion regulation. This pragmatic randomized controlled superiority trial investigated the efficacy of MBT-C compared with a group-based parenting and child social skills intervention (PSSG) at 12 weeks (primary end point) and 36-week follow-up (secondary end point). Method: The trial included 222 children (mean age-7.89; 34% girls) at clinical levels of internalizing, externalizing, or co-occurring internalizing and externalizing problems and their families equally randomized to MBT-C or PSSG. Assessments took place at baseline, 8 and 12 weeks, and 24-and 36-week follow-up. Primary outcomes were children's internalizing, externalizing, and total problems. Secondary outcomes were parent and child emotion regulation, child global function, parent mentalizing, and parenting stress. Results: There were no statistically significant differences between MBT-C and PSSG in reducing children's total, internalizing, or externalizing problems at 12 weeks; however, MBT-C was superior at 36 weeks on total problems with a small effect (d-0.479, 95% CI [0.105, 0.854]). MBT-C was also superior in improving emotion regulation of parents (d-0.248, 95% CI [0.002, 0.493]) and children (d-0.221, 95% CI [ 0.435, 0.006]) and child-reported problems (d-0.331, 95% CI [0.029, 0.633]) at 12 weeks with small effects. These differential treatment effects were maintained during follow-up. Conclusion: MBT-C demonstrated a small superior effect to PSSG in treating overall problems over the longer term, but not immediately after the intervention, in school-age children with internalizing and externalizing problems. However, as a single-site study, generalizability is limited, and further research supporting treatment efficacy is warranted. Plain language summary: This randomized controlled trial compared the efficacy of Mentalization-Based Treatment for Children (MBT-C) to a parenting and child social skills group (PSSG) in 222 school-age children with internalizing and externalizing problems. There were significant improvements in children's emotional and behavioral problems in both interventions at the end of the treatments. However, children who received MBT-C showed significantly more reductions in their levels of problems compared to children who received PSSG at 6-month follow-up. Compared to PSSG, both children and parents in MBT-C showed significantly greater improvements in their emotion regulation capacities at the end of treatment, which were sustained during follow-up. Overall, the effect sizes for these relative improvements at follow-up were small. Clinical trial registration information: The Effectiveness and Change Mechanisms of Mentalization Based Therapy for Children (MBT-C); NCT05290714; https://clinicaltrials.gov/study/NCT05290714.