Reflective Functioning and Psychotherapy Processes in Mentalization Based Therapy

BACKGROUND Borderline personality disorder (BPD) BPD is a pervasive mental disorder characterized by emotional instability, self-destructive behavior, identity problems and unstable interpersonal relationships. The disorder is associated with high levels of symptom distress, suicidal behavior, psychosocial impairment, and high rates of comorbid mental disorders such as mood, anxiety, and substance use disorders, as well as significant health service utilization and costs. Recent research has found the prognosis of BPD to be better than previously assumed. Yet, despite high rates of diagnostic remission many patients continue to have poor vocational and social functioning.

Several specialized and evidence based psychotherapies targeting characteristic BPD symptoms have been developed during the past decades, like Dialectical behavioral therapy, Transference focused therapy, Schema focused therapy and Mentalization based therapy. Across specific treatment approaches the outcome of therapy is typically variable, some patients respond well to treatment, whereas others respond less or even deteriorate. It is therefore important to understand how treatment works in order to improve therapies and tailor treatment to individual patients.

Mentalization based therapy (MBT) MBT is a manualized psychodynamic psychotherapy which focuses specifically on the patients' mentalizing difficulties. Mentalization is defined as the capacity to perceive human behavior as expressions of mental states, like thoughts, affects, dreams and intentions, and is usually operationalized as Reflective Functioning (RF) assessed by the RF Scale. Impaired mentalizing capacity is an assumed core aspect of BPD underlying characteristic features such as poor affect regulation, impulse control problems, and incoherent internal representations of self and others leading to unstable relationships and self- esteem. MBT is prototypically a combined treatment program comprising individual and group therapy, as well as psychoeducation. Several studies, including RCTs have documented positive effects of MBT in terms of reduced suicidal behavior, symptoms, interpersonal problems, medication, and health service use. There are also indications that MBT may be particularly helpful for more severely disturbed patients with extensive comorbidity.

Yet, no study has investigated whether patients' mentalizing capacity changes during MBT, or to what degree outcome of MBT is mediated by improved RF. One study found that outcome of two different treatment approaches (not MBT) differentially depended on patients' pretreatment levels of RF, indicating that RF may be a valuable variable for treatment selection and outcome. There are also indications that RF may improve during Transference focused therapy. However, there is a general lack of studies investigating the role of RF in the unfolding of psychotherapy processes and outcome of MBT. Thus, more studies are needed to gain knowledge of mechanisms of change in MBT.

RF and psychotherapy processes Common therapeutic factors are factors that are believed to function across different types of treatment, in contrast to specific factors which are seen as operating as part of specific therapies and interventions. An early good therapeutic alliance between patient and therapist is the most widely recognized common factor in individual therapies. The Working Alliance Inventory is an established method for assessment of therapeutic alliance in individual therapy. As to group therapies alliance to therapists and group members, as well as group cohesion are suggested as important common factors, but the evidence is not consistent. Assessment of therapeutic factors in groups is, however more complicated due to the many relationships in therapy groups. The Group Questionnaire is a promising empirically derived instrument intended to comprise important dimensions of a patient's relationship to his/her therapy group.