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Fluctuation of RF Scale applied to sessions, across ten sessions each for Ms. A. (left) and Ms. B. (right)
Source publication
This study examines how reflective functioning (RF) can be assessed in analytic sessions and throughout psychoanalytic psychotherapy. The goals are to replicate in part a study by Josephs and colleagues (2004) by applying the RF Scale to analytic sessions and to study fluctuations of RF within each session. Additionally, RF based on sessions was co...
Contexts in source publication
Context 1
... expected fluctuations of RF within each session were found in all of twenty sessions we examined. Figure 1 shows the fluctuations of session-based RF in the sessions. Fluctuations were studied as follows: each session was divided into 150- word blocks and rated for RF, the RF scores were transferred to a table of RF scores per session, and then an overall RF score was given each ses- sion. ...
Context 2
... analyzing the complete data set for the twenty sessions, it became clear that both patients showed a relative increase of moderate to high RF scores per session over the duration of the treatment (e.g., 16% of RF ratings of 5 at a baseline session increased to 46% of such ratings at a session around 240 hours for Ms. B.). In Figure 1, fluctuations of RF per session and patient are pre- sented in a vertical bar per session. For example, in Ms. A.'s first session, her level of RF fluctuated between 3 and 7. ...
Context 3
... of the sessions shown in Figure 1 will serve as an example of how the RF score was applied on the patient's narrative throughout a session of ...
Context 4
... psychotherapy. Session number 3 from Ms. A. (the third vertical bar in Figure 1) is analyzed in greater detail in Figure 2. The patient's statements are shown that were used to code RF; the therapist's interventions are not transcribed but summarized (see boxes below). Ms. A. came into psychoanalytic psychotherapy reporting depressive symptoms, problems with sexuality, and difficulties distancing herself from others' wishes. ...
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Citations
... and then one of the two raters scored the remaining session transcripts in the same manner. Other case studies have similarly assessed client RF from blocks as small as 150 words (Hörz-Sagstetter et al., 2015;Talia et al., 2019). Client speaking turn RF scores were averaged in 5-min segments, allowing us to examine RF within sessions. ...
Meta-analysis has found a significant relation between rupture–repair and client outcome (Eubanks et al., 2018). Rupture–repair processes may be particularly important in psychotherapy for pregnancy loss wherein ruptures related to client feelings of shame and inadequacy, the societal invalidation of perinatal grief, and reenactments in the therapy relationship of early attachment experiences have been theorized to be common and important events (Markin, 2024). Thus, it is important to understand what occurs on a microlevel during the process of therapy to ultimately explain the rupture resolution (RR) and treatment outcome association. In particular, while both the therapist and client are believed to contribute to ruptures and to their repair (Safran & Muran, 2000), little is known about how therapist contributions impact rupture events, rupture resolution, and treatment progress. Further, client reflective functioning (RF) may represent a set of capacities that contribute to and are increased by rupture resolution yet vary depending on the role of the therapist in the rupture. The current investigation examined how observer-rated therapist contribution to ruptures and client RF were related to rupture events, rupture resolution, and client-reported symptom change and session quality over 22 sessions of psychodynamic therapy for pregnancy after loss. Therapist contribution to ruptures predicted rupture significance, high and steady within-session client RF scores, and symptom change. Client RF and rupture resolution predicted symptom change differently, often depending on type of symptom. Importantly, client RF and rupture resolution may predict successful outcomes through ameliorating commonly reported symptoms during pregnancies after loss.
... To our knowledge, fluctuations in mentalizing have not been studied in naturalistic settings. However, several psychotherapy studies examined momentary mentalizing capacities by applying observer-rated coding of mentalizing to patient utterances in short-term intervals within sessions (e.g., individual talk-turns or intervals of several minutes) and showed that such fluctuations do exist (Hörz-Sagstetter et al., 2015;Josephs et al., 2004;Karlsson & Kermott, 2006;Katz et al., 2017;Kivity et al., 2021;Möller et al., 2017). Because within-and between-person effects are often independent of one another (Molenaar, 2004), ignoring these within-person effects means overlooking a possibly crucial aspect of mentalizing -that is, that mentalizing is a dynamic capacity that may fluctuate over time. ...
Mentalizing, the capacity to consider mental states, is a fundamental and essential capacity that is associated with mental health. Studies mostly assess mentalizing in lab, neglecting its ecological aspects and short-term fluctuations. The current study presents preliminary psychometric findings from a novel method of assessing mentalizing dynamics in daily life. We also examined how daily life mentalizing is related to features of borderline personality disorder (BPD) which is known to show mentalizing impairments. Twenty non-clinical participants were interviewed for mentalizing capacity and completed self-report measures of mentalizing and BPD features at baseline. Then, participants completed a weeklong ecological momentary assessment (EMA) including six daily surveys of self-reported mentalizing and audio-recorded descriptions of current mental states, and a continuous assessment of stress using wearable devices. Narrative materials were coded using an observer-rated measure of mentalizing. Completion rates were high (M = 94%; NEMAs = 726). Lab and EMA-based observer-rated mentalizing were moderately correlated (r = .41). About 67% of the variability in observer-rated mentalizing was at the within-person level and inter-rater reliability was fair (0.50 – 0.57). Better momentary self-reported mentalizing predicted better momentary observer-rated mentalizing. Better momentary observer-rated mentalizing predicted greater stress levels. BPD features tended to predict larger fluctuations in momentary observer-rated mentalizing.The novel method provides an ecological way to assess momentary mentalizing with adequate convergent and predictive validity. The preliminary findings show that mentalizing is highly dynamic in daily life and suggest that these dynamics are possibly related to momentary stress and BPD features.
... A number of studies included in this review employed Fonagy's construct of mentalization (Fonagy, 2002). One study (Hörz-Sagstetter et al., 2003) noted the similarity to aspects of social cognition, mindfulness and psychological mindedness. Another study utilised the construct of mentalization but posed a definition that included interactional processes rather than a distinct internalised ability (Keselman et al., 2018). ...
... A similar study but with a much smaller number (n = 2) described qualitative markers of RF as attempts by the client to understand themselves and others in terms of mental states (Hörz-Sagstetter et al., 2003). This study attempted to track improvements in scores of the RF scale over 300 h of therapy, and included a measure of therapist actions (psychotherapy Q-set). ...
... Other studies presented unexpected results such as RF remaining stable, or decreasing over therapy sessions (Brockmann et al., 2018). In another study fluctuations in RF were noted to be related to baseline measures of RF and it was difficult to determine the effect of therapy on measurements of RF (Hörz-Sagstetter et al., 2003). A study seeking to track change in metacognition during therapy did not find significant differences in "self-reflectivity" (Arnon-Ribenfeld et al., 2018). ...
Psychological therapies use talk as a means to produce change for individuals who are experiencing distress. Despite a significant body of research comparing approaches, there is little evidence for the superiority of one model over another. The process of reflection has been suggested as a common factor across modalities, and research aiming to measure this phenomenon is emerging. This scoping review is focussed on the conceptualisations, measurement and process outcomes of reflective talk as it occurs during therapy. Twenty-two studies were selected from a total of 3712 papers identified following a systematic search of SCOPUS, MEDLINE, PsychINFO and Web of Science databases. A variety of descriptors emerged: intrapersonal constructs such as mentalization and metacognition tended to view reflectivity as an individually acquired skill or trait, where other descriptors adopted an interpersonal understanding of reflection as co-constructed through dialogue. Our findings suggest a shift from individual to intersubjective understandings of reflecting processes in therapy may be a valuable area for future research.
... Second, RF could be assumed a mediator of change: an improvement in RF might enable a better understanding of one's own affects and the behavior of others, thus reducing interpersonal problems or difficulties in affect regulation. Overall, improvement in RF was most consistently found in psychodynamic treatments (35,(40)(41)(42)(43). This might be due to a focus on "insight" and reflecting on emotional processes in relationships. ...
... Notably, the capacity to mentalize can be good or poor, but mentalizing in a specific situation is also context-dependent and has been shown to fluctuate within and between sessions in psychotherapeutic processes (41,45). Psychotherapy sessions will differ depending on attachment-related arousal and content, and a therapist might or might not stimulate RF. ...
... Therefore, it is important to distinguish between a general capacity to mentalize and mentalizing in a psychotherapy session, although both will be interdependent. In this sense, a higher general capacity to mentalize, as measured with the Reflective-Functioning Scale applied to the adult attachment interview (AAI), was found to be associated with higher RF in psychotherapy sessions (41,46). In sum, more research is needed to examine the relevance of mentalizing/RF in psychotherapeutic processes of different mental disorders, including EDs. ...
Objective
Previous research suggests that patients with anorexia nervosa (AN) show an impaired capacity to mentalize (reflective functioning, RF). RF is discussed as a possible predictor of outcome in psychotherapeutic processes. The study aimed to explore RF in sessions of patients with AN and its association with outcome and type of treatment.
Methods
A post-hoc data analysis of selected cases from a randomized trial on outpatient psychotherapy for AN was conducted. Transcripts from 84 sessions of 28 patients (early phase, middle phase, and end of treatment) were assessed using the In-Session-Reflective-Functioning-Scale [14 cognitive-behavior therapy, enhanced (CBT-E); 14 focal psychodynamic therapy (FPT); 16 with good, 12 with poor outcome after 1 year]. Relations between the level of RF, type of treatment, and outcome were investigated using mixed linear models. Additionally, associations with depressive symptoms, weight gain, and therapeutic alliance were explored.
Results
Mean in-session RF was low. It was higher in FPT when compared to CBT-E treatments. The findings point to an association between RF increase and a positive outcome. An increase in BMI in the first half of treatment was associated with higher subsequent in-session RF. There was no association between RF and depressive symptoms or the therapeutic alliance.
Discussion
Patients with AN show a low capacity to mentalize in sessions, which seems to be at least partly dependent on the degree of starvation. The results suggest a possible relationship between an increase in in-session RF and outcome, which has to be replicated by further studies.
... Despite a lack of comprehensive evidence, it is widely believed that improvements in RF go along with betterment in personality functioning (Zettl et al., 2020) as, for example, assessed in Criterion A of the alternative model for the classification of personality disorders in the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5;American Psychiatric Association, 2013). Although RF may be a relevant transdiagnostic mechanism of change in psychotherapy and useful to track the therapeutic process (Talia et al., 2019), only few studies collected longitudinal data of RF (more than two measuring points): one study in a sample of borderline personality disorder (BPD; Möller et al., 2017), one in bulimia (Katznelson et al., 2020), and two case studies with personality disorders and social phobia as primary diagnoses (Hörz-Sagstetter et al., 2015;Josephs et al., 2004). ...
The ability to mentalize has been discussed as potential change mechanism in psychotherapy. Reflective functioning (RF) offers an empirical framework for the assessment of mentalization in therapy sessions. In the present study, we assessed RF longitudinally and examined its association with symptomatic distress, symptom severity of depression and anxiety, and interpersonal problems over the course of treatment. Thirty-seven patients diagnosed with depression or anxiety disorders received 25 ± 3 sessions of integrative cognitive-behavioral therapy (CBT) in an outpatient setting. The observer-rated in-session Reflective Functioning Scale (RFS) was applied to transcripts of therapy Sessions 1, 8, 16, and 24. The effects of RF were investigated both within and between patients using hierarchical linear modeling. RF significantly increased over the course of treatment, and this improvement in RF was significantly associated with depressive symptoms. This means that after a session where patients positively deviated from their own average RF during treatment, they reported lower depression severity. In post hoc analyses, we found a significant interaction effect of the within- and between-patient RF effects on interpersonal problems. Patients with overall higher levels of RF and with positive deviations from their own average RF over the course of treatment tended to have less interpersonal problems during psychotherapy. The present study contributes to the preliminary evidence that changes in RF may serve as a common factor in psychotherapy in contrast to being a specific factor in psychodynamic therapies. More longitudinal studies are necessary to gain a better understanding of RF as a change mechanism in psychotherapy. (PsycInfo Database Record (c) 2021 APA, all rights reserved).
... One would have also expected to find significant changes on the RFQ_C after the EI training. Nonetheless, lack of such a finding is compatible with previous research which showed no changes in self-understanding after a 4-week EI training (Nelis et al., 2009) and that significant changes in RF require more intense work and are obtained over long-term therapeutic work (Levy et al., 2006;Hörz-Sagstetter et al., 2015). ...
Emotional Intelligence (EI) is considered an ability which helps to recognize and regulate of one’s own and others’ emotions. EI was suggested to be one of the important factors for maintaining a successful personal and professional life. EI is considered as an ability that can be developed through practice. Thus, numerous studies attempted to examine effects of EI training programs. This study examined the effects of an intensive three-day training program on EI, difficulties in emotional regulation, reflective functioning, and psychological symptoms. The participants were 18 adults in the treatment group and 18 adults in the control group. The results showed that the EI training have led to a significant decrease in difficulties in emotional regulation over three days of training among participants in the treatment group. In particular, participants’ in the treatment group impulse control difficulties decreased, whereas such a decrease was not observed in the control group. There was some increase in the Reflective Functioning Uncertainity scores of the participants’ in the treatment group. There were no significant changes in overall emotional intelligence and psychological symptoms. The findings suggested that the intensive EI training led to better impulse control ability and an increase in mentalizing capacity.
... Our first hypothesis, that people with secure attachment would show significantly higher RF and more adaptive defensive functioning than insecure individuals, was fully confirmed by the findings. Consistent with literature and empirical contributions in the field (Besharat & Khajavi, 2013;Boldrini, Lo Buglio, Giovanardi, Lingiardi, & Salcuni, 2020;Malik et al., 2015;Bouchard et al., 2008;Fonagy & Target, 1997Hörz-Sagstetter, Mertens, Isphording, Buchheim, & Taubner, 2015;Nazzaro et al., 2017), the results indicate the shared line of development of two very important aspects of psychological functioning, such as mentalization and emotion regulation, that take place in early relationships with sensitive and responsive caregivers as main sources of the development of secure internal working models of attachment (Bowlby, 1969;Carrère & Bowie, 2012;Hershenberg et al., 2011). Conversely, we confirmed Besharat and Khajavi's idea (2013) that massive use of immature defense mechanisms in insecure attachment may be aimed to react against mental distress by blocking awareness of negative emotions. ...
Mentalizing capacities depends on the quality of primary attachment interactions with caregivers who thinks of the child as a subject with mental states. Operationalized as reflective functioning, mentalization is crucial for regulating emotions and developing
of a coherent sense of identity, for interacting with individuals making sense to own and others mental states, and for distinguishing internal and external realities without distortions. Although the clinical literature on interplay between mentalization,
attachment, and emotional regulation is rich, the empirical research is limited. This study sought to explore connections between reflective functioning, attachment styles, and
implicit emotion regulation, operationalized as defense mechanisms, in a group of depressive patients. Twenty-eight patients were interviewed using the Adult Attachment Interview (AAI) and diagnosed using the Psychodynamic Chart-2 of the Psychodynamic
Diagnostic Manual, Second Edition. The reflective functioning scale and the Defense Mechanisms Rating Scale Qsort were applied to AAI transcriptions to assess reflective functioning and defensive profile. Patients with secure attachment showed significantly higher levels in reflective functioning and overall defensive functioning as compared to those with insecure attachment. Good reflective functioning and secure attachment
correlated with mature defenses and specific defensive mechanisms that serve in better regulating affective states. Overall, the relationship between mentalization, attachment and emotion regulation lay the foundations for the delineation of defensive profiles associated with attachment patterns and reflective functioning in depressive patients. The systematic assessment of these psychological dimensions with gold-standard tools may help in tailoring personalized therapeutic interventions and promoting more effective treatments.
... Como respuesta, sólo recientemente, a partir de la adaptación de la RFS al campo de la psicoterapia (eg. Hörz-Sagstetter et al., 2015;Martínez et al., 2017, Talia et al., 2019 se han comenzado a realizar estudios de proceso en psicoterapia, un aporte significativo que ha permitido evaluar el despliegue de la mentalización momento a momento durante las intervenciones clínicas. ...
Objetivo:
Basado en la falta de medidas que permitan evaluar la mentalización como variable de proceso en psicoterapias con adolescentes, el siguiente estudio apunta a presentar el diseño de un sistema observacional para evaluar el despliegue de esta variable tanto en pacientes como en terapeutas.
Método:
mediante el proceso de codificación abierta de la teoría fundamentada y análisis temático de tres niveles, se analizó el despliegue de la mentalización tanto en terapeutas como en pacientes en 10 episodios de ruptura y 10 episodios de resolución elegidos aleatoriamente de cinco psicoterapias con adolescentes.
Resultados:
A partir del análisis efectuado se desarrolló un sistema observacional de seis dimensiones emergentes (foco en los estados mentales, opacidad de los estados mentales, comunicación contingente, causalidad de los estados mentales, naturaleza dinámica de los estados mentales y foco en el momento presente) denominado “Sistema de Observación de la mentalización en Psicoterapia con adolescentes” (OMP-A) que permite evaluar cuantitativamente la mentalización de terapeutas y pacientes.
Discusión y conclusiones:
el OMP-A es un instrumento que responde a debilidades de otros sistemas para evaluar mentalización en psicoterapia con adolescentes, permitiendo la observación de aspectos lingüísticos y paralingüísticos del mentalizar y toma en consideración aspectos particulares que caracterizan las intervenciones con adolescentes. Se discute su posible uso para la formación y supervisión en psicoterapia, y los desafíos metodológicos para desarrollos futuros.
... In a separate study, improvements in RF were also correlated with improvements in personality functioning after one year of TFP (Fischer-Kern et al., 2015). RF was also a moderator and predictor of therapeutic outcome in a few studies of psychotherapies for conditions other than BPD (Boldrini et al., 2018;Gullestad et al., 2013;Hörz-Sagstetter et al., 2015;Müller et al., 2006;Taubner et al., 2011). ...
Objective: The Reflective Function (RF) Scale is the original validated measure of mentalizing, applied to Adult Attachment Interview (AAI) transcripts. This study aimed to replicate the preliminary validation of Computerized RF (CRF), a computerized text analysis measure of RF.
Methods: 49 women with borderline personality disorder (BPD; n = 20) and without (n = 29) completed diagnostic interviews and the AAI. AAIs were scored by certified coders using the RF Scale, and by computerized text analysis software using CRF dictionaries.
Results: CRF significantly correlated with RF. The frequency of High CRF words had moderate-to-strong correlations with RF in the total sample (rs = .47), BPD group (rs = .61), and non-BPD group (rs = .41). Adding the frequency of Low CRF words to create a proportion of High and Low CRF words, and applying CRF to AAIs trimmed to include only items that “demand” RF, both produced significant, but not stronger, correlations with RF.
Conclusion: CRF is an efficient alternative to the RF Scale that can estimate mentalization. Near average levels, neither RF nor CRF significantly differentiated between groups, indicating mentalizing deficits may not always be present, detectable, or defining in BPD samples. While more research is needed, CRF is a valid assessment of RF when codable text is available.
... In this regard, the present investigation showed an inverse relationship between positive psychotic symptoms and adaptive defenses, as well as a positive relationship between psychotic defenses and negative symptoms. Moreover, evidence suggests that a patient's ability of work through and reflect on his or her defenses is also related to a strengthening of the patient's psychological capacities, and especially an increase in his or her ability to mentalize (e.g., Boldrini et al., 2018;Hörz-Sagstetter, Mertens, Isphording, Buchheim, & Taubner, 2015;Levy et al., 2006). It is known that UHR individuals, as patients with schizoid and schizotypal personality disorders (Nazzaro et al., 2017), are characterized by impairment in social cognition (Armando, Hutsebaut & Debbane, 2019; Bora & Pantelis, 2013). ...
Research within psychotherapy and psychopathology frameworks has been inspired by the central concept of defense mechanisms, which play a pivotal role in psychoanalysis. Defense specificities have only recently been studied systematically in the context of several clinical diagnoses. The present study aimed to explore the specificities of defense mechanisms in adolescents at ultra-high risk of developing psychosis and test the relationship between defensive functioning and attenuated psychotic symptoms. Twenty-six adolescent inpatients at ultra-high risk of developing psychosis and a matched clinical control group of inpatients not at risk of psychosis were interviewed. Two observer-rater methods, the Defense Mechanism Rating Scales and the Psychotic-Defense Mechanism Rating Scales were applied to interview transcripts to assess the individual use of defenses. Ultra-high-risk patients demonstrated lower defense mechanisms (i.e., total instances of defense mechanisms observed) and lower overall adaptiveness of the defenses presented. When specific differences between groups were observed, psychotic defenses were the sole defenses that could partially discriminate between ultra-high-risk and not at-risk patients. Regarding the relationship between defense mechanisms and subthreshold psychotic symptoms, psychotic defenses were associated with negative and disorganization symptoms, rather than with positive symptoms. The psychological vulnerability of ultra-high-risk patients is discussed and treatment implications for psychotherapy with such challenging patients are addressed.
