Questions
• What is RF? How did the concept
arise? (How does an organized sense of
self emerge? What can disrupt it? What
can repair it?)
• What are the clinical findings involving
RF?
• What is mentalization-based therapy
MBT?
ORIGINS OF RF
London Parent-Child Project (low-risk sample)
Forensic sample of violent criminals
Clinical sample with Axis 1 & Axis 2 disorders
The London Parent-Child Project
Miriam and Howard Steele
• An urban, non-clinical, 70% university
educated, middle class sample of 100
couples expecting their first child
• Assessed during pregnancy, 12 months,
18 months, 5 years, 6 years,11 & 17
years
Adult Attachment Interview (George, Kaplan & Main, 1985)
• What happened?
• 5-adjectives for early
relationship w/mother
and w/father
• Emotionally upset?
• Physically hurt?
• Separated? Rejected?
• Abuse? Loss?
• What do you make of
it?
• Why do you think your
parents behaved the way
they did?
• Has childhood influenced
the kind of person you
are today?
The first RF scale
(metacognitive monitoring enlarged)
• Scores of 1-3: Truisms, banal attributions; scant evidence that the
speaker thinks either about motives that guided their parents’ behavior
toward them, or their own actions/responses
• Scores of 4-5: Either a general understanding of human motives but it
is not applied to the speaker’s own experiences, or conclusions drawn
about own experience seem inaccurate or do not distinguish between
child and adult thought processes
• Scores of 6-9: Organized and consistent effort to understand one’s
own behavior (as child and as adult), of the parents (then and now)
and of the interdependence of these processes
Reflective Functioning as a Therapeutic Aim
• Reflective functioning is defined as the psychological
capacity for understanding one’s own mental states,
thoughts, feelings and intentions as well as those of the
other.
• Therapists facilitate reflective function in the patient
with respect to:
• current and past realities, and roles played by self and
others in determining one’s thoughts/feelings
• differences and similarities between fantasy and reality
• words as regulators of affect
Indicators of past deprivation
• Prolonged separation (>3mos) from parents before age
11
• Single - parent family
• Low SES
• Paternal unemployment > 3 months
• Severe illness in mother or father
• Boarding school experience before age 11
Frequency of secure and insecure infantmother classifications grouped by mothers’
past experiences of deprivation and present
reflective-functioning (Fonagy, Steele, Steele, Higgitt &
Target, 1994, Emmanuel Miller Lecture, Journal of Child Psychology
& Psychiatry).
Reflective Functioning is seen in speech that shows:
• an understanding of the nature of mental states
• a relational perspective (mental states in one
influence mental states in the other)
• a developmental perspective re ‘the there and
then’
• an appreciation for demands of the current
context, or ‘the here and now’
Mothers’ RF scores from their prenatal AAIs and 3
correlates: with
1. infant-mother attachment at one
year
2. child’s theory of mind & emotion
at five years
3. child’s capacity to tell a coherent
autobiographical narrative at age
eleven years
Fathers’ RF scores from their prental AAIs and 3
correlates:
1. security of infant-father attachment at
one year
2. fathers’ (and mothers’) lower reports
of withdrawn, delinquent and
aggressive behavior at five years
(CBCL)
3. lower self-reported emotional,
behavioral and peer problems at age
eleven years
Reflective Functioning scores of
in-patients at the Cassel Hospital
(after Fonagy, Leigh, Steele, Steele et al, 1996)
*p<.05, **, p<.01, ***p<.001
Adult Attachment Interviews in forensic samples:
The 9-point RF scale becomes an 11-point scale
(Levinson & Fonagy, 2002; van IJzendoorn et al. 1997)IJzendoorn)
• Score of -1: Hostile, refutation of the worthiness of being reflective,
anti-reflective, rejection
• Score of 0: Absent RF. Repeated neutral statements of ‘I don’t know?’
• Scores of 1-3: Truisms, banal attributions; scant evidence that the speaker thinks either about motives that
guided their parents’ behavior toward them, or their own actions/responses
• Scores of 4-5: Either a general understanding of human motives but it is not applied to the speaker’s own
experiences, or conclusions drawn about own experience seem inaccurate or do not distinguish between
child and adult thought processes
• Scores of 6-9: Organized and consistent effort to understand one’s own behavior (as child and as adult), of
the parents (then and now) and of the interdependence of these processes
BATEMAN & FONAGY (2008) AM J PSYCHIATRY
8-YEAR FOLLOW-UP OF PATIENTS TREATED FOR
BPD: MBT VERSUS TREATMENT AS USUAL
“The focus of the therapy is on the patient’s
moment-to-moment state of mind. The patient and
therapist collaboratively try to generate alternative
perspectives to the patient’s subjective experience of
himself or herself and others by moving from
validating and supportive interventions to exploring
the therapy relationship itself as it suggests
alternative understanding. This psychodynamic
therapy is manualized and in many respects
overlaps with transference-focused psychotherapy”
p. Bateman & Fonagy, 2008, p. 632)
HARRY AT 12-MONTHS
WITH MOTHER
on reunion during which her son was very distressed,
and he only really settles after mother says, in response
to a vocalization and gesture from her son ‘oh that’s the
little man you were playing with before.....’
Reflective Functioning is seen in speech that shows:
• an understanding of the nature of mental states
• a relational perspective (mental states in one
influence mental states in the other)
• a developmental perspective re ‘the there and
then’
• an appreciation for demands of the current
context, or ‘the here and now’
Overview of the RF manual
1. Introduction
2. Why RF is so important
3. Validation of the measure
4. Illustrations of moderate to high RF
5. General considerations
6. Illustrations of negative or limited RF
7. Rating passages
17
4.1 Awareness of the nature of mental states
• opaqueness (4.11)
• mental states as amenable to disguise
•
•
•
(4.12)
recognizing limits on insight (4.13)
mental states tied to expressions of
normative judgement (4.14)
awareness of defensive nature of certain
mental states (4.15)
18
4.2 Trying to tease out (‘abstract with difficulty’) mental
states underlying behavior
• accurate attributions of mental states to others (4.2.1)
• envisioning the possibility that feelings concerning a
situation may be unrelated to observable aspects of it
(4.2.2)
• recognition of diverse perspectives (4.2.3)
• taking into account one’s own mental state in
interpreting others (4.2.4)
• evaluating mental states from the point of view of their
impact on behavior of the self or others (4.2.5)
19
4.2 Trying to tease out (‘abstract with difficulty’) mental
states underlying behavior cont.
• taking into account how others perceive oneself (4.2.6)
• a freshness of recall and thinking about mental states
(4.2.7)
20
4.3 Recognizing developmental aspects of mental states
• taking an intergenerational perspective (4.3.1)
• taking a developmental perspective (4.3.2)
• revising thoughts and feelings about childhood in the
light of understanding gained since (4.3.3)
• envisioning changes of mental states between past
and present, or present and future (4.3.4)
• envisioning transactional processes between parent
and child (4.3.5)
• understanding factors that developmentally influence
affect regulation (4.3.6)
• awareness of family dynamics (4.3.7)
21
4.4 Mental states in relation to the interviewer
• acknowledging the separateness of minds
(4.4.1)
• not assuming knowledge (4.4.2)
• emotional attunement (4.4.3)
22
5. General considerations
• only explicitly reflective statements qualify for high
ratings (5.1)
• learned, rote, or cliché statement do not qualify for
high ratings (5.2)
• reference to a personality type, or relationship type,
in the absence of specific references to mental
states, does not qualify for a high rating (5.3)
• avoid thinking for the speaker (5.4)
• diagnoses should not be accepted as shorthand for
mental states (5.5)
23
6. Ilustrations of negative or limited RF
•
•
•
•
•
•
rejection (6.2)
unintegrated, bizarre or inappropriate (6.3)
disavowal (6.4)
distorting/self-serving (6.5)
naive/simplistic (6.6)
overly analytic or hyperactive RF (6.7)
24
7. Rating passages
• demand versus permit questions (7.1)
• guidelines for rating identified passages (7.2), e.g.
each loss separately, each attachment-figure
separately
• in aggregating ratings, demand questions weigh more,
but high RF answers to permit questions may indicate
a habit of mind that counts for a high score and
justifies brevity to (later) demand questions (7.3)
• the overall rating and in-between scores; low RF in
response to permit questions contributes to lower
overall scores; though 2-3 scores of ‘3’ do not
preclude an overall very high rating of 8 (7.4)
25
Bowlby,1951,p.84
On Parenting
• Just as children are absolutely dependent
on their parents for sustenance, in all but
the most primitive communities, are
parents, especially mothers, dependent on
a greater society for economic provision. If
a community values its children it must
cherish their parents.