Discussion
deterioration of symptoms, psychopathy, aggression, depressive, depressed, depressive symptoms, substance abuse
DISORDER, PATHOLOGY, RECRUITMENT
This study investigated the feasibility of MBT-CD for adolescents in terms of acceptability of intervention and scientific assessments by participants as well as necessary organizational resources. The following aspects supporting feasibility were identified: First, adolescents with CD could be recruited for participation. Second, once adolescents stayed beyond session two, they completed treatment with high probability. However, recruitment was slow, especially when recruitment networks were not yet established. Moreover, follow-up acceptance of scientific assessments was low. In line with the well-known difficulty to reach this group (e.g., [The screening–recruitment ratio of ~ 2:1 and low drop-out rates after the third individual session point to high relevance of very first contacts with adolescents with CD for therapy adherence. Several aspects characteristic for the sample of this study have previously been identified as risk factors for drop-out of adolescent psychotherapy as e.g., conduct problems, youth in middle adolescence [Moreover, feasibility seems likely to be fostered by several center characteristics: Whenever possible, treatment should be offered at the location of the first contact with the adolescents. Scientific assessments should optimally be short and conducted in a familiar environment, e.g., by their therapist or directly before or after treatment sessions by a researcher.It seems to be partly feasible to teach MBT-CD to therapists of different therapeutic backgrounds without prior MBT experience by conducting a one- or two-day training and regular supervision. Yet, as not all therapists were adherent, one may speculate whether different therapeutic orientations came along with specific difficulties for example with taking the not-knowing mentalizing stance or exploring underlying mental states rather than behavior. Moreover, a lack of MBT adherence might result from the “contagious” potential of a patient’s non-mentalizing [The following treatment aspects might be considered in future trials: Both patient and study center characteristics seem important for the observed range in treatment duration. Treatments with low session numbers were conducted in Mainz with younger adolescents (< = 14 years). Treatments were characterized by inconsistent attendance of both, adolescents and their parents. High session numbers were conducted in Heidelberg with older adolescents (> = 16 years) and treatments were characterized by high complexity of symptom etiology, high psychopathy and/or legal complexity. The overall study treatment phase in Mainz was shorter than in Heidelberg (18 vs. 36 months). Additionally, PT orientation of therapists in Heidelberg and predominant CBT orientation in Mainz might have contributed to longer and shorter treatment durations, respectively. Based on these findings, MBT-CD might need to be adapted depending on the adolescents’ age or maturity: for adolescents aged 14 or younger, the first and highly structured phase of MBT-CD in combination with frequent family sessions may suffice. For adolescents 15 years or older, individual sessions might play a greater role with a focus on etiology of their aggression and negative (legal) consequences of their behavior. This is supported by implications drawn from results of the structured content analysis of the Heidelberg subsample: younger individuals seemed to prefer and benefit more from the more structured phase of the intervention, while older individuals may have benefitted more from the mentalizing processes unfolding over the course of their therapy [One patient reported deterioration of symptoms in that she felt more depressed. With respect to future studies, this is a concerning albeit plausible outcome, as reduction of aggression might not uncommonly be succeeded by depressive symptoms. Thus, depressive symptomatology needs to be monitored throughout the study and cared for, respectively. This is also true for frequent comorbid substance use disorder. While substance use is not an exclusion criterion for MBT-CD, it should be focused on from the beginning and patients may need inpatient treatment for substance abuse prior to MBT-CD.Potential center effects became apparent in the preliminary pre–post analyses as well as in the treatment evaluations by the adolescents: In Heidelberg, self-reported empathy pathology and aggression were reduced while this was not evident in the Mainz sample. Regarding treatment evaluations, adolescents in Heidelberg indicated they were annoyed by therapists’ questions, while adolescents in Mainz explicitly valued the non-patronizing stance of their therapists. While both aspects likely represent the mentalizing stance, the centers may have differed in their focus on adopting aspects of the stance, resulting in different perceptions by adolescents. However, due to the small sample size and lack of controlled investigation of skilful MBT implementation in the centers, these aspects need further investigation.