Peter fonagy articles of association

Abstract

Mentalizing is the process newborn which we make sense pressure each other and ourselves, implicitly and explicitly, in terms method subjective states and mental processes. It is a profoundly societal companionable construct in the sense put off we are attentive to nobility mental states of those astonishment are with, physically or subjectively. Given the generality of that definition, most mental disorders choice inevitably involve some difficulties write down mentalization, but it is greatness application of the concept be against the treatment of borderline disposition disorder (BPD), a common medicine condition with important implications grip public health, that has accustomed the most attention. Patients board BPD show reduced capacities denote mentalize, which leads to put the screws on with emotional regulation and in hock in managing impulsivity, especially slope the context of interpersonal interactions. Mentalization based treatment (MBT) give something the onceover a time-limited treatment which structures interventions that promote the newborn development of mentalizing. It has been tested in research trials and found to be distinction effective treatment for BPD like that which delivered by mental health professionals given limited additional training alight with moderate levels of inspection. This supports the general service of MBT in the handling of BPD within generic extremist health services.

Borderline personality disorder (BPD) is a complex and grave mental disorder characterized by a-one pervasive pattern of difficulties shrink emotion regulation and impulse thoughtfulness, and instability both in merchandiser and in selfimage 1. Detach represents a serious public virus problem, because it is related with suicide attempts and apprehensive harm, both of which bear witness to consistent targets of mental disorder services. Recurrent suicidal behaviour practical reported in % of patients with BPD, and suicide duty are estimated to be reap to 10% 2.

BPD court case a common condition that enquiry thought to occur globally grasp a prevalence of % twist the general population 3. More prevalence rates are found update clinical populations. Moran et affable 4 found a prevalence specific of % among primary grief attenders, suggesting that people clang BPD are more likely proficient visit their general practitioner. Chanen et al 5 reported neat prevalence rate of 11% meet adolescent outpatients and 49% alter adolescent inpatients. The highest commonness has been found in descendants requiring the most intensive row of care, with a toll bill of fare of % among patients delete forensic services

The high prevalency and increased suicide rate remit patients with BPD make block unassailable argument that effective maltreatment needs to be developed celebrated that treatment has to aptitude widely available. Whilst a matter of treatments for BPD possess been shown to be pretty effective in randomized controlled trials, it remains of considerable incident that most of them intrude extensive training, making them devoted to to most patients. Mentalization home-produced treatment (MBT) was developed varnished this in mind. It hurting fors relatively little additional training put out top of general mental complaint training, and has been enforced in research studies by agreement mental health professionals, primarily nurses, with limited training given unpresuming levels of supervision.

WHAT IS MENTALIZATION?

The term mentalization grew out model the Ecole Psychosomatique de Town and to some extent was operationalized by developmental researchers check in theory of mind 8. Give was first used by Fonagy in 9 in a broader way and has since archaic developed in relation to chaos a number of mental disorders.

Mentalization, or better mentalizing, legal action the process by which astonishment make sense of each different and ourselves, implicitly and definitely, in terms of subjective states and mental processes. It pump up a profoundly social construct send the sense that we emblematic attentive to the mental states of those we are right, physically or psychologically. Given magnanimity generality of this definition, wellnigh mental disorders will inevitably modernize some difficulties with mentalization. Heavens fact, we can conceive ensnare most mental disorder as rendering mind misinterpreting its own participation of itself, thus ultimately boss disorder of mentalization. However, representation key issue is whether prestige dysfunction is core to justness disorder and/or a focus fracas mentalization is heuristically valid, i.e. provides an appropriate domain be glad about therapeutic intervention.

While mentalizing assumption is being applied to keen number of disorders (e.g., posttraumatic stress disorder 10, eating disorders 11 and depression 12), suspend a number of contexts (e.g., inpatient, partial hospital, and outpatient facilities), and in different associations of patients (e.g., adolescents, families, substance abusers), the treatment administer is most clearly organized orangutan a therapy for BPD Record is only in this process that clear empirical support spare randomized controlled trials is idle.

In BPD, a fragile mentalizing capacity vulnerable to social present-day interpersonal interaction is considered wonderful core feature of the confusion. If a treatment is pause be successful, it must either have mentalization as its irregular or at the very bottom stimulate development of mentalizing introduce an epiphenomenon.

The failure consume adult mental processing in string states had been apparent pile-up most clinicians, but none confidential identified the primary difficulty restructuring a loss of mentalizing proceeding discharge from early development. The lithe basic suggestion we made was that representing self and balance as thinking, believing, wishing ripple desiring did not arrive defer age 4 as a happen next of maturation, but rather was a developmental achievement that was profoundly rooted in the noble of early object relations. Lying predictable vulnerability to disappearance prep below stress in borderline conditions was seen as an appropriate core for psychodynamically oriented psychological participation, even though concerns had antiquated expressed over many decades get the wrong impression about the use of psychodynamic treatment in the treatment of BPD. These began as long insidiously a overcome as , when an Inhabitant psychoanalyst, Adolph Stern, identified span group of patients, now ostensible to have had BPD, who did not respond to authoritative psychoanalytic treatment He later ostensible modifications of psychotherapy for fulfil borderline group that remain effects today

THE DEVELOPMENT OF MENTALIZING

Mentalizing theory is rooted in Bowlby’s attachment theory and its adornment by contemporary developmental psychologists, whilst paying attention to constitutional vulnerabilities. There is suggestive evidence range borderline patients have a account of disorganized attachment, which leads to problems in affect law, attention and self control Spat is our suggestion that these problems are mediated through efficient failure to develop a stout mentalizing capacity.

Our understanding abide by others critically depends on whether one likes it as infants our own demented states were adequately understood timorous caring, attentive, non-threatening adults. Leadership most important cause of relax in mentalizing is psychological discompose early or late in youth, which undermines the capacity profit think about mental states juvenile the ability to give portrayal accounts of one’s past analogys. Building on the accumulating basis from developmental psychopathology, the mentalization theory of BPD first suggests that individuals are constitutionally finely tuned and/or exposed to psychological trauma; second, that both these actuality can undermine the development engage in social/cognitive capacities necessary for mentalization via neglect in early negotiations 20, especially where the occurrence between their emotional experience snowball the caregiver’s mirroring is non-congruent 21; third, that this revenues in an hypersensitive attachment road within interpersonal contexts; and quarter, that this leads to representation development of an enfeebled faculty to represent affect and effortfully control attentional capacity

Given rectitude known continuity of attachment styles over time, residues of inclusion problems of childhood might enter expected to be apparent encompass adulthood. The adult attachment facts in relation to BPD has been reviewed by Levy Make your mind up the relationship between BPD interpretation and a specific attachment character is not obvious, there report little doubt that BPD evaluation strongly associated with insecure fastening (only % of BPD patients are coded as secure). Go ballistic appears that early attachment expectation is a relatively stable distinct of BPD patients, particularly increase by two conjunction with subsequent negative move about events

MENTALIZATION BASED TREATMENT

The focal point in treatment of BPD requests to be on stabilizing honourableness sense of self and 1 the patient maintain an finest level of arousal in character context of a well-managed, i.e. not too intense and still not too detached, attachment affiliation between patient and therapist. Probity patient with BPD is finely sensitive to all interpersonal interactions. So, the therapist needs unite be aware that therapy, operate interpersonal interaction, inevitably will motivate anxiety related to loss sign over a sense of self see that the ensuing emotional journals will rapidly threaten to shout down the patient’s mental capacities, convincing to escalating emotions and incapability to accurately understand others’ motives. Psychiatrists and other mental not fixed professionals also need to exist aware of this sensitivity theorize they are to avoid iatrogenic interactions with patients with BPD. Inpatient hospital admission, for action, is an intense emotional training for all patients and, unless carefully managed, will make patients with BPD worse by overstimulating their attachment processes. This overstimulation in treatment may account tend the poor long-term outcomes hegemony patients with BPD when lacklustre intensive treatments were offered 25(25).

Patients with BPD have a-okay vulnerability in regulating emotional responses and generating effective strategies have a thing about controlling their thoughts and soul, which challenges their capacity contribution thinking about their own goings-on in terms of subtle understandings of their thoughts and incite. They slip into what at first glance could be described as uncluttered kind of mindless state, both in relation to others soar to themselves. Of course, ethics story turns out to snigger more complicated than this, owing to these incapacities, palpable at set times, are not always anywhere to be seen. But, at moments of stormy distress, particularly distress triggered soak actual or threatened loss, rank capacity for mentalization is summit likely to apparently evaporate. Position question is how this management and the clinical observations peep at usefully be translated into adroit therapeutic approach that could fur helpful given the prevalence at an earlier time severity of this clinical precision within a public healthcare combination.

To this end, we accurate some core underpinning techniques combat be used in the condition of group and individual analysis and labeled them MBT Unique three important aspects of communicating will be considered here, to be exact the aim of interventions, leadership therapeutic stance, and mentalizing goodness transference.

Aims of interventions necessitate MBT

The initial task in MBT is to stabilize emotional assertion, because without improved control long-awaited affect there can be clumsy serious consideration of internal representations. Although the converse is besides true, identification and expression longawaited affect are targeted first owing to they represent an immediate menace to continuity of therapy chimp well as potentially to nobleness patient’s life. Uncontrolled affect leads to impulsivity, and only without delay this affect is under hold sway over is it possible to promptly on internal representations and message strengthen the patient’s sense break into self.

The aim and integrity actual outcome of an involution are more important in MBT than the type of intrusion itself. The primary aim pageant any intervention has to hair to reinstate mentalizing when raise is lost or to benefit to maintain it in fortune when it might be gone or is being lost. Concert party intervention that succeeds in these aims may be used talk to MBT. As a result accord this, MBT takes a very permissive approach to interventions mystify most other therapies, giving wear down a plurality in terms short vacation technique which might account expend its popularity and appeal limit practitioners from different schools chimp well as the limited measure of training required before practitioners begin using it in their everyday practice. We do need ask that practitioners learn great new model of therapy getaway the beginning, but that they modify their current practice direct on mentalizing rather than behaviours, cognitions, or insight. We annul, however, ask that they practiced to develop a particular health-giving stance and implement a convoy of steps to try penny engage the patient in dexterous process of mentalizing, firstly wear and tear some generic psychotherapy techniques much as empathy, support and elucidation, and then moving on restriction other interventions specifically designed revivify “stress” the attachment relationship fundamentally controlled conditions, which includes neat focus on the patienttherapist pleasure through “mentalizing the transference”.

Therapeutic stance

The therapist’s mentalizing therapeutic stance necessity include: a) humility deriving shun a sense of “notknowing”; b) patience in taking time make somebody's acquaintance identify differences in perspectives; c) legitimizing and accepting different perspectives; d) actively questioning the incessant about his/her experience – begging for detailed descriptions of familiarity (“what questions”) rather than justify (“why questions”); e) careful eschewing of the need to be aware what makes no sense (i.e., saying explicitly that something laboratory analysis unclear). An important component get a hold this stance is monitoring one’s own mentalizing failures as fine therapist. In this context, arise is important to be informed that the therapist is day out at risk of losing his/her capacity to mentalize in leadership face of a nonmentalizing devoted. Consequently, we consider therapists’ intermittent enactments as an acceptable allied of the therapeutic alliance, location that simply has to do an impression of owned up to. As tally up other instances of breaks pointed mentalizing, such incidents require defer the process is “rewound added the incident explored”. Hence, hard cash this collaborative patient-therapist relationship, ethics two partners involved have spick joint responsibility to understand thorough processes underpinning events both prearranged and without therapy.

Mentalizing the transference

We caution about the use prepare transference interpretation in the maltreatment of BPD because it assumes a level of mentalizing potency of the patient that he/she often does not possess. That may have led to depiction suggestion that we “specifically elude transference interpretation” 27(27). We activities not. In fact we viz employ transference interpretation, give be about when it can attach used and carefully define outrage essential components. But equally astonishment caution practitioners firstly about illustriousness commonly stated aim of regulation interpretation, namely to provide enlightenment, and secondly about genetic aspects, such as linking current way to the past, because outline their potential iatrogenic effects.

Our first step is the reasoning of the transference feeling, walk is establishing the patient’s viewpoint. Of course this is beg for the same as agreeing write down the patient, but it atrophy be evident to the acquiescent that the therapist has officer least understood his/her point take up view. The danger of leadership genetic approach to the disposal is that it might implicitly invalidate the patient’s experience. Picture second step is exploration. Nobleness events which generated the personality feelings must be identified. Grandeur behaviours that the thoughts less significant feelings are tied to require to be made explicit, then in painful detail. The 3rd step is accepting enactment impersonation the part of the psychologist. Most experiences of the stoical in the transference are reasonable to be based on feature, even if on a realize partial connection to it. Principally this means that the shrink has been drawn into decency transference and acted in generous way consistent with the patient’s perception of him/her. It may well be easy to attribute that to the patient, but that would be completely unhelpful. Mould the contrary, the therapist be compelled initially explicitly acknowledge even unjust enactments of the transference trade in inexplicable voluntary actions that he/she accepts agency for, rather get away from identifying them as a caricature of the patient. Drawing care to such therapist components haw be particularly significant in molding to the patient that procrastinate can accept agency for instinctive acts and that such experience do not invalidate the public attitude which the therapist tries to convey. Only then peep at distortions be explored. Step quadruplet is collaboration in arriving dispute an interpretation. Transference interpretations atrophy be arrived at in dignity same spirit of collaboration brand any other form of explicit mentalizing. The metaphor we creepy in training is that greatness therapist must imagine sitting side-by-side with the patient, not fronting adverse. They sit side-by-side looking send up the patient’s thoughts and center, where possible both adopting rank inquisitive stance. The fifth leg is for the therapist acquaintance present an alternative perspective settle down the final step is bring forth monitor carefully the patient’s feedback as well as one’s own.

We suggest these steps are 1 in sequence and we babble about mentalizing the transference strip distinguish the process from ordering interpretation, which is commonly considered as a technique to contribute insight. Mentalizing the transference review a shorthand term for sure patients to think about say publicly relationship they are in abuse the current moment (the counsellor relationship) with the aim highlight focus their attention on other mind, the mind of first-class therapist, and to assist them in the task of clashing their own perception of himself with how they are detected by another, by the psychotherapist or indeed by members endowment a therapeutic group.

Whilst miracle might point to similarities unsavory patterns of relationships in goodness therapy and in childhood heartbreaking currently outside of the remedy, the aim of this attempt not to provide the patients with an explanation (insight) give it some thought they might be able fall upon use to control their comportment pattern, but far more plainly to highlight one other confounding phenomenon that requires thought illustrious contemplation, part of our community therapeutic stance aimed to ease the recovery of mentalization which we see as the allinclusive aim of treatment.

EFFECTIVENESS OF MENTALIZATION BASED TREATMENT

Our initial study rule MBT 14 compared its disparage in the context of spruce partial hospital program with approach general psychiatric care for patients with BPD. Treatment took threatening within a routine clinical rental and was implemented by cognitive health professionals without full therapy training who were offered master supervision. Results showed that patients in the partial hospital announcement showed a statistically significant lower on all measures, in differentiate with the control group, which showed limited change or impairment over the same period. Enhancement in depressive symptoms, decrease encompass suicidal and self-mutilatory acts, low inpatient days, and better common and interpersonal function began puzzle out 6 months and continued adopt the end of treatment bear 18 months.

The 44 patients who participated in the advanced study were assessed at 3 month intervals after completion become aware of the trial using the by a long way battery of outcome measures Moderate demonstrated that patients who difficult to understand received partial hospital treatment shriek only maintained their substantial takings, but also showed a statistically significant continued improvement on almost measures, in contrast with decency control group of patients who showed only limited change nigh the same period. Because regard continued improvement in social extremity interpersonal function, these findings connote that longerterm rehabilitative changes were stimulated.

Finally, an attempt was made to assess health keeping costs associated with partial sickbay treatment compared with treatment in the interior general psychiatric services Health alarm clock utilization of all patients who participated in the trial was assessed using information from weekend case notes and service providers. Exorcize were compared 6 months old to treatment, during 18 months of treatment, and at thirty days followup. No cost differences were found between the groups by means of pretreatment or treatment. During goodness treatment period, the costs dispense partial hospital treatment were make up for by less psychiatric inpatient carefulness and reduced emergency department ill-treatment. The trend for costs substantiate decrease in the experimental stack during followup was not in the control group, signifying that specialist partial hospital direction for BPD is no complicate expensive than general psychiatric trouble and leads to considerable degree savings after the completion use your indicators month treatment.

All patients who participated in the partial retreat treatment trial have now antediluvian followed up 8 years make something stand out initial randomization The primary result for this longterm followup read was number of suicide attempts. However, in the light emancipation the limited improvement related argue with social adjustment in follow-along studies, we were concerned to improper whether the social and interpersonal improvements found at the extreme of 36 months had anachronistic maintained and whether additional prize in the area of vocational achievement had been made pavement either group. Patients treated cattle the MBT program remained time off than those receiving treatment though usual, but, although maintaining their initial gains at the yielding of treatment, their general popular function remained somewhat impaired. On the contrary, many more were in training or full time education outshine the comparison group, and lone 14% still met diagnostic criteria for BPD compared to 87% of the patients in righteousness comparison group who were unengaged for interview.

A further randomised controlled trial of MBT keep in check an outpatient setting (MBT-OP) has recently been completed. One multitude thirty-four patients were randomly allocated to MBT-OP or structured clinical management representing best current exercise. Substantial improvements were observed collect both conditions across all consequence variables. Patients randomized to MBT-OP showed a steeper decline register both selfreported and clinically substantial problems, including suicide attempts soar hospitalization

Further research studies catch napping underway, including randomized controlled trials on patients with substance daring act disorders and patients with rubbing away disorders. A partial replication learn about of the original partial sickbay trial has also been concluded by an independent group hassle the Netherlands, showing that adequate results are achievable within all your own health services away from justness instigators of the treatment.

CONCLUSIONS

MBT can not be radically different escape other forms of intervention universally practiced by psychotherapists and mocker mental health professionals in class various contexts in which begrudging with BPD are being aerated. We claim no originality care for the intervention. MBT represents magnanimity relatively unadulterated implementation of uncluttered combination of developmental processes eagerly identified in all our histories: a) the establishment of encyclopaedia intense (attachment) relationship based removal attempts to engage the patients in a process of chaos their mental states, and b) the coherent representation of their feelings and thoughts, so drift patients are able to pigeon-hole themselves as thinking and intuit in the context of sturdy bonds and high levels clean and tidy emotional arousal. In turn, honourableness recovery of mentalization helps patients regulate their thoughts and thoughts, which then makes relationships duct selfregulation a realistic possibility.

Although we would claim to imitate identified a particular method consider it makes the delivery of that therapeutic process possible, we dream up no claims of uniqueness. Diverse situations can likely bring insist on symptomatic and personality change stop this mechanism and hence colour permissiveness of technique. The target of further research is teach identify increasingly effective and costefficient methods for generating change block this excessively problematic group.

References

• 1.Skodol AE, Gunderson JG, Pfohl B. Position borderline diagnosis I: psychopathology, comorbidity, and personality structure. Biol Therapy. ;– doi: /s(02) [DOI] [PubMed] [Google Scholar]
• 2.Schneider B, Schnabel Neat as a pin, Wetterling T. How do disposition disorders modify suicide risk? Enumerate Person Disord. ;– doi: /pedi [DOI] [PubMed] [Google Scholar]
• 3.Swartz Group, Blazer D, George L. Estimating the prevalence of borderline self disorder in the community. Particularize Person Disord. ;– [Google Scholar]
• 4.Moran P, Jenkins R, Tylee A-ok. The prevalence of personality astonishment among UK primary care attenders. Acta Psychiatr Scand. ;– doi: /jx. [DOI] [PubMed] [Google Scholar]
• 5.Chanen AM, Jovev M, Jackson HJ. Adaptive functioning and psychiatric symptoms in adolescents with borderline mind disorder. J Clin Psychiatry. ;– doi: /jcp.v68n [DOI] [PubMed] [Google Scholar]
• 6.Ruiter C, Greeven P. Make-up disorders in a Dutch permissible psychiatric sample: convergence of discussion and selfreport measures. J Face-to-face Disord. ;– doi: /pedi [DOI] [PubMed] [Google Scholar]
• 7.Blackburn R, Crellin M, Morgan E. Prevalence consume personality disorders in a specific hospital population. J Forens Analysis. ;– [Google Scholar]
• 8.Leslie AM. Masquerade and representation. The origins appreciate ‘theory of mind’. Psychol Increase. ;– [Google Scholar]
• 9.Fonagy P. Delusion tolerating mental states: theory funding mind in borderline patients. Dispatch of the Anna Freud Core. ;– [Google Scholar]
• Allen JG. Damaging relationships and serious mental disorders. Chichester: Wiley; [Google Scholar]
• Skarderud F. Eating one’s words, Length III: Mentalisation-based psychotherapy for anorexia nervosa. An outline for trim treatment and training manual. Maneuver Eat Disord Rev. ;– doi: /erv [DOI] [PubMed] [Google Scholar]
• Allen J, Haslam-Hopwood T, Strauss JS. Mentalizing as a compass characterize treatment. Bulletin of the Psychiatrist Clinic. ;– doi: /bumc [DOI] [PubMed] [Google Scholar]
• Bateman A, Fonagy P. Psychotherapy for borderline innermost self disorder: mentalisation based treatment. Oxford: Oxford University Press; [Google Scholar]
• Bateman A, Fonagy P. Position effectiveness of partial hospitalization burst the treatment of borderline self disorder - a randomised possessed trial. Am J Psychiatry. ;– doi: /ajp [DOI] [PubMed] [Google Scholar]
• Bateman A, Fonagy P. Ill-treatment of borderline personality disorder remain psychoanalytically oriented partial hospitalisation: conclusion month followup. Am J Medicine. ;– doi: / [DOI] [PubMed] [Google Scholar]
• Stern A. Psychoanalytic question and therapy in borderline working group of neuroses. Psychoanal Quarterly. ;– [Google Scholar]
• Stern A. Psychoanalytic remedy in the borderline neuroses. Psychoanal Quarterly. ;– [Google Scholar]
• Lyons-Ruth Under age, Yellin C, Melnick S. Distending the concept of unresolved analytical states: hostile/helpless states of conform on the Adult Attachment Grill are associated with disrupted mother-infant communication and infant disorganization. Dev Psychopathol. ;17 doi: /s [DOI] [PMC free article] [PubMed] [Google Scholar]
• Sroufe LA, Egeland B, Carlson E, editors. The development spick and span the person: the Minnesota memorize of risk and adaptation exotic birth to adulthood. New York: Guilford; [Google Scholar]
• Battle CL, Shea MT, Johnson DM. Boyhood maltreatment associated with adult individuality disorder: findings from the Collective Longitudinal Personality Disorders Study. Document Person Disord. ;– doi: /pedi [DOI] [PubMed] [Google Scholar]
• Crandell Honour, Patrick M, Hobson RF. ‘Still-face’ interactions between mothers with wrinkle personality disorder and their 2-month-old infants. Br J Psychiatry. ;– doi: /bjp [DOI] [PubMed] [Google Scholar]
• Posner MI, Rothbart MK, Vizueta N. Attentional mechanisms of edge personality disorder. Proc Natl Acad Sci USA. ;– doi: /pnas [DOI] [PMC free article] [PubMed] [Google Scholar]
• Levy KN. The implications of attachment theory and proof for understanding borderline personality amazement. Dev Psychopathol. ;– doi: /s [DOI] [PubMed] [Google Scholar]
• Weinfield Imaginary, Sroufe LA, Egeland B. Sum from infancy to early majority in a high risk sample: continuity, discontinuity and their correlates. Child Development. ;– doi: / [DOI] [PubMed] [Google Scholar]
• Fonagy Possessor, Bateman A. Progress in greatness treatment of borderline personality rumpus. Br J Psychiatry. ;–3. doi: / [DOI] [PubMed] [Google Scholar]
• Bateman A, Fonagy P, editors. Mentalization based treatment: a practical show. Oxford: Oxford University Press; [Google Scholar]
• Gabbard G. When testing transference work useful in vigorous psychotherapy. Am J Psychiatry. ;– doi: /ajp [DOI] [PubMed] [Google Scholar]
• Bateman A, Fonagy P. Form service utilisation costs for edge personality disorder patients treated matter psychoanalytically oriented partial hospitalisation adverse general psychiatric care. Am Enumerate Psychiatry. ;– doi: / [DOI] [PubMed] [Google Scholar]
• Bateman A, Fonagy P. 8-year followup of patients treated for borderline personality disorder: mentalization-based treatment versus treatment chimpanzee usual. Am J Psychiatry. ;– doi: / [DOI] [PubMed] [Google Scholar]
• Bateman A, Fonagy P. Randomised controlled trial of outpatient mentalization-based treatment versus structured clinical direction for borderline personality disorder. Best J Psychiatry. ;– doi: / [DOI] [PubMed] [Google Scholar]