Page 123 - Personality disorders and insecure attachment among adolescents

who had not previously engaged in the behaviour to begin doing so in clinical practice. Reducing self- blame and enhancing positive refocusing and positive reappraisal could be important treatment targets. General Discussion In this thesis, three important results emerged. First, observational practice-based research among clinical adolescents is complicated due to specific circumstances that must be considered, especially concerning treatment outcome. Wherefore the course of action for current research in adolescent personality pathology is questionable. Second, a high rate of co-occurrence exists between personality disorders, insecure attachment representations and NSSI among clinical adolescents. Third, over the course of intensive MBT substantial positive changes occur in clinical adolescents: not only in personality disorders and symptomology, but also in attachment insecurity. In this discussion, these outcomes are further explored. Observational practice-based research among clinical adolescents The high-risk adolescents this thesis focusses on have hardly been studied before. In randomised clinical trials (RCTs), considered the highest standard of evidence, these patients are mostly excluded, because they are characterised by comorbidity and all too often lack motivation. This is surprising, since the (financial) burden of this group of patients on society is substantial due to, among others, the direct medical costs of self-inflicted injury including NSSI and suicide attempts. This observational practice-based study differed from the research conducted in controlled specialty settings by studying a real-world practice with clinical adolescents. By doing so, this study provides rare insights into clinical adolescents with personality pathology, insecure attachment and NSSI. Only a subgroup of patients who were included in this study could be followed from the start until the end of treatment, despite many attempts to reach and motivate them. Several circumstances seem to complicate research on adolescents. First, adolescents are difficult to motivate to participate in research projects without reward, especially in studies with questionnaires in a pre-post design. Participating in research is undoubtedly even more difficult for clinical adolescents due to their psychopathology. Second, adolescents generally think short term and are guided by the here and now, which influences outcomes per measurement moment. Similarly, adolescence is a period of emotional maturation, characterised by big leaps forward and backwards in developmental tasks, such as separation-individuation and identity formation (Kaltiala-Heino & Eronen, 2015). Young people grow and show change until at least 23 years of age. As a result, it is unclear if, for instance, the outcomes of intensive treatment in adolescence are the effect of treatment given, natural developmental change or a combination of both. At the same time, adolescence is a developmental phase in which 119