Reflective Functioning: What It Is, Why It Matters & How Therapy Can Help

One capacity that research increasingly shows to be important for our social wellbeing and emotional regulation is reflective functioning or mentalisation — the ability to think about, understand and respond to one’s own and others’ mental states.

What is Reflective Functioning?

Reflective functioning (abbreviated to RF) was developed within attachment research to measure how well someone can reflect on mental states: their own and those of others. The scale was popularised by Howard Steele and Peter Fonagy in the context of the Adult Attachment Interview.

When asked to reflect on why one’s parent acted a certain way, high RF means you can “mentalise” about what might have been going on for them, for example:

• “I suspect my father was angry and couldn’t handle it when I was crying because I think perhaps his own parents were quite cold and distant with him and his emotions when he was a child.”

Low RF might show up as simplistic, vague or unengaged, hyperactive/fragmented, or dismissive responses, e.g.:

• “He was just a narcissist”

• “I don’t know… Whatever the usual reasons would be for someone to get angry.”

• “How should I know why he did that?”

What the Research Tells Us

RF matters because it influences how we relate to ourselves, how we make sense of our emotional life, and how we connect with others. For example, one crucial finding is that parental RF seems to plays a crucial role in the intergenerational transmission of attachment (Slade et al., 2005). Not only was mothers’ own attachment linked to their RF (higher RF = secure attachment), it was also predictive of their infants attachment, such that mothers with higher RF were associated with secure attachment in their infants, whereas mothers with lower RF were associated with insecure attachment in their infants.

Given its direct connection to our attachment as well as the attachment of our potential dependents, this arguably provides us with a solid incentive to take notice of our RF.

Client Outcomes

Impaired RF is thought to play a central role in borderline personality disorder (BPD) which is characterised by difficulties in emotional regulation and in relationships with others. A study by Keefe et al. (2022) of 194 patients with BPD found that patients with high baseline RF had better outcomes in general, and that psychodynamic therapies were especially effective in improving outcomes for those with initially low RF.

Therapists’ RF equally appears to matter for client outcomes. A study found that clients of therapists with higher RF experienced greater symptom reduction compared to clients of therapists with low RF who saw no significant changes (Cologon et al., 2017).

In short: RF matters for therapy outcomes — both in clients and therapists.

Early Trauma & borderline Personality Disorder

RF also appears to moderate the impact of early relational trauma. A study by Fonagy et al. (1996) shows that when early physical or sexual abuse is present and RF is low, there is a significantly higher prevalence of BPD. Conversely, when RF is higher, the impact of trauma may be buffered because the individual can reflect on and make sense of early experiences rather than be overwhelmed by them.

This suggests RF is not only important for therapy but may also be part of how healthy personality develops in the face of adversity.

RF Can Be Increased Through Therapy

Good news: RF is changeable. Studies have shown that therapies can increase reflective functioning over time. For example, research on Transference-Focused Psychotherapy (TFP) — a structured form of psychodynamic therapy which invites clients to consider mental states through the focus on the relationship between the therapist and the client — has shown significant improvements in clients’ RF during treatment (Kivity et al., 2021).

TFP is based on core principles of psychodynamic therapy: exploring unconscious patterns, working through relational dynamics, and especially paying attention to the transference — the way past emotional experiences and expectations are replayed in the therapeutic relationship. In that sense, TFP is a specialised subtype of psychodynamic therapy, one that specifically targets reflective functioning through the live exploration of mental states and relational patterns in the here-and-now.

Similarly, Mentalization-Based Therapy (MBT), developed by Peter Fonagy and Anthony Bateman, is another evolution of psychodynamic thinking. It draws directly from attachment theory and focuses on helping clients recover and strengthen their ability to mentalize — that is, to understand behaviour in terms of underlying mental states. While MBT is a manualised approach, its foundations are psychodynamic: it assumes that reflective capacity develops (and can be repaired) within safe, attuned relationships.

what this means and what you can do?

Together, these findings suggest that reflective functioning grows in relational, psychodynamic contexts, especially when the therapeutic relationship is used as a living laboratory for understanding how we relate to ourselves and others.

At ECPT, our therapy service works from a existential-psychodynamic frame, meaning that in addition to paying attention to different existential challenges and dilemmas, we explore how one’s early relational world has shaped them, how it’s playing out in their current relationships, and we also look at the transference between themselves and the therapist in the therapy room, much like TFT does to increase RF.

If you’re interested in exploring this further, feel free to reach out to us or explore further reading below.

References

• Cologon, J., Schweitzer, R. D., King, R., & Nolte, T. (2017). Therapist Reflective Functioning, Therapist Attachment Style and Therapist Effectiveness. Administration and policy in mental health, 44(5), 614–625. https://doi.org/10.1007/s10488-017-0790-5

• Fonagy, P., Leigh, T., Steele, M., Steele, H., Kennedy, R., Mattoon, G., Target, M., & Gerber, A. (1996). The relation of attachment status, psychiatric classification, and response to psychotherapy. Journal of consulting and clinical psychology, 64(1), 22–31. https://doi.org/10.1037//0022-006x.64.1.22

• Keefe, J. R., Levy, K. N., Sowislo, J. F., Diamond, D., Doering, S., Hörz-Sagstetter, S., Buchheim, A., Fischer-Kern, M., & Clarkin, J. F. (2022). Reflective Functioning and Its Potential to Moderate the Efficacy of Manualized Psychodynamic Therapies Versus Other Treatments for Borderline Personality Disorder. Journal of consulting and clinical psychology, 91(1), 50-56. https://doi.org/10.1037/ccp0000760

• Kivity, Y., Levy, K. N., Kelly, K. M., & Clarkin, J. F. (2021). In-session reflective functioning in psychotherapies for borderline personality disorder: The emotion regulatory role of reflective functioning. Journal of consulting and clinical psychology, 89(9), 751–761. https://doi.org/10.1037/ccp0000674

• Slade, A., Grienenberger, J., Bernbach, E., Levy, D., & Locker, A. (2005). Maternal reflective functioning, attachment, and the transmission gap: A preliminary study. Attachment & Human Devlopment, 7(3), 283-298.